1. A nurse is preparing to administer a medication to a patient. Which of the following
actions should the nurse take to ensure patient safety?
A) Verify the patient's identity using their room number.
B) Check the patient's identification band and ask the patient to state their name.
C) Administer the medication if the patient is asleep.
D) Wait until the next shift to administer the medication.
Answer: B) Check the patient's identification band and ask the patient to state their name.
Rationale: The nurse should verify the patient’s identity using two identifiers (e.g., the patient’s
name and birthdate or ID band) before administering medications to ensure safety and avoid
errors.
2. A nurse is caring for a patient with a nasogastric tube. Which of the following actions
should the nurse take to verify proper tube placement before administering a medication?
A) Auscultate over the stomach for a gurgling sound.
B) Check the pH of aspirated stomach contents.
C) Use a stethoscope to listen for bowel sounds.
D) Confirm placement by visual inspection of the tube.
Answer: B) Check the pH of aspirated stomach contents.
Rationale: Checking the pH of the aspirated fluid is the most accurate method to verify proper
placement of a nasogastric tube.
3. A nurse is teaching a patient about the importance of turning every 2 hours to prevent
pressure ulcers. Which of the following is the rationale for this recommendation?
A) Improves circulation to the affected area.
B) Increases the risk of skin irritation.
C) Reduces the risk of infection.
D) Prevents the breakdown of muscle tissue.
Answer: A) Improves circulation to the affected area.
Rationale: Turning the patient every 2 hours helps to relieve pressure on bony prominences,
improving circulation and reducing the risk of pressure ulcers.
4. The nurse is assessing a patient’s skin for signs of dehydration. Which of the following is
an early sign of dehydration?
,A) Weight gain.
B) Decreased skin turgor.
C) Rapid weight loss.
D) Edema in lower extremities.
Answer: B) Decreased skin turgor.
Rationale: Decreased skin turgor is an early sign of dehydration, indicating that the skin loses its
elasticity due to fluid loss.
5. A nurse is caring for a patient who is receiving oxygen therapy. The nurse should
monitor for which of the following potential complications of oxygen therapy?
A) Hypothermia
B) Oxygen toxicity
C) Hypoglycemia
D) Hyperkalemia
Answer: B) Oxygen toxicity
Rationale: Prolonged or high-concentration oxygen therapy can lead to oxygen toxicity, causing
symptoms such as respiratory distress, chest pain, and seizures.
6. A nurse is educating a patient on proper hand hygiene. Which of the following actions
should the nurse include in the teaching?
A) Use alcohol-based hand sanitizer when hands are visibly soiled.
B) Wash hands for at least 20 seconds with soap and water.
C) Rub hands together for 5 seconds to remove dirt.
D) Use alcohol-based hand sanitizer after handling sterile equipment.
Answer: B) Wash hands for at least 20 seconds with soap and water.
Rationale: The CDC recommends washing hands with soap and water for at least 20 seconds to
remove dirt, bacteria, and viruses, especially when hands are visibly soiled.
7. A nurse is caring for a patient who has been placed on bed rest. Which of the following
interventions should the nurse implement to prevent deep vein thrombosis (DVT)?
A) Encourage the patient to remain still.
B) Provide passive range-of-motion exercises.
C) Apply a heating pad to the affected leg.
D) Place a pillow under the patient’s knees.
, Answer: B) Provide passive range-of-motion exercises.
Rationale: Passive range-of-motion exercises help improve circulation and reduce the risk of
DVT in patients on bed rest.
8. A nurse is preparing to insert a urinary catheter in a female patient. Which of the
following is an appropriate action for the nurse to take?
A) Cleanse the urinary meatus from back to front.
B) Use a clean, dry cloth to clean the urinary meatus.
C) Insert the catheter without lubrication to minimize discomfort.
D) Place the patient in a supine position with knees slightly apart.
Answer: D) Place the patient in a supine position with knees slightly apart.
Rationale: Positioning the patient in a supine position with knees slightly apart provides optimal
access for catheter insertion.
9. A nurse is caring for a postoperative patient. Which of the following interventions should
the nurse prioritize to prevent atelectasis?
A) Encourage the patient to deep breathe and cough.
B) Administer pain medications as prescribed.
C) Restrict fluid intake to avoid aspiration.
D) Elevate the head of the bed to 45 degrees.
Answer: A) Encourage the patient to deep breathe and cough.
Rationale: Deep breathing and coughing exercises help prevent atelectasis by promoting lung
expansion and clearing secretions.
10. A nurse is assessing a patient who is experiencing a myocardial infarction. Which of the
following findings should the nurse expect?
A) Hypotension and bradycardia
B) Shortness of breath and chest pain
C) Hypertension and bradycardia
D) Nausea and diaphoresis
Answer: B) Shortness of breath and chest pain
Rationale: Common symptoms of myocardial infarction include chest pain, shortness of breath,
nausea, and diaphoresis.
actions should the nurse take to ensure patient safety?
A) Verify the patient's identity using their room number.
B) Check the patient's identification band and ask the patient to state their name.
C) Administer the medication if the patient is asleep.
D) Wait until the next shift to administer the medication.
Answer: B) Check the patient's identification band and ask the patient to state their name.
Rationale: The nurse should verify the patient’s identity using two identifiers (e.g., the patient’s
name and birthdate or ID band) before administering medications to ensure safety and avoid
errors.
2. A nurse is caring for a patient with a nasogastric tube. Which of the following actions
should the nurse take to verify proper tube placement before administering a medication?
A) Auscultate over the stomach for a gurgling sound.
B) Check the pH of aspirated stomach contents.
C) Use a stethoscope to listen for bowel sounds.
D) Confirm placement by visual inspection of the tube.
Answer: B) Check the pH of aspirated stomach contents.
Rationale: Checking the pH of the aspirated fluid is the most accurate method to verify proper
placement of a nasogastric tube.
3. A nurse is teaching a patient about the importance of turning every 2 hours to prevent
pressure ulcers. Which of the following is the rationale for this recommendation?
A) Improves circulation to the affected area.
B) Increases the risk of skin irritation.
C) Reduces the risk of infection.
D) Prevents the breakdown of muscle tissue.
Answer: A) Improves circulation to the affected area.
Rationale: Turning the patient every 2 hours helps to relieve pressure on bony prominences,
improving circulation and reducing the risk of pressure ulcers.
4. The nurse is assessing a patient’s skin for signs of dehydration. Which of the following is
an early sign of dehydration?
,A) Weight gain.
B) Decreased skin turgor.
C) Rapid weight loss.
D) Edema in lower extremities.
Answer: B) Decreased skin turgor.
Rationale: Decreased skin turgor is an early sign of dehydration, indicating that the skin loses its
elasticity due to fluid loss.
5. A nurse is caring for a patient who is receiving oxygen therapy. The nurse should
monitor for which of the following potential complications of oxygen therapy?
A) Hypothermia
B) Oxygen toxicity
C) Hypoglycemia
D) Hyperkalemia
Answer: B) Oxygen toxicity
Rationale: Prolonged or high-concentration oxygen therapy can lead to oxygen toxicity, causing
symptoms such as respiratory distress, chest pain, and seizures.
6. A nurse is educating a patient on proper hand hygiene. Which of the following actions
should the nurse include in the teaching?
A) Use alcohol-based hand sanitizer when hands are visibly soiled.
B) Wash hands for at least 20 seconds with soap and water.
C) Rub hands together for 5 seconds to remove dirt.
D) Use alcohol-based hand sanitizer after handling sterile equipment.
Answer: B) Wash hands for at least 20 seconds with soap and water.
Rationale: The CDC recommends washing hands with soap and water for at least 20 seconds to
remove dirt, bacteria, and viruses, especially when hands are visibly soiled.
7. A nurse is caring for a patient who has been placed on bed rest. Which of the following
interventions should the nurse implement to prevent deep vein thrombosis (DVT)?
A) Encourage the patient to remain still.
B) Provide passive range-of-motion exercises.
C) Apply a heating pad to the affected leg.
D) Place a pillow under the patient’s knees.
, Answer: B) Provide passive range-of-motion exercises.
Rationale: Passive range-of-motion exercises help improve circulation and reduce the risk of
DVT in patients on bed rest.
8. A nurse is preparing to insert a urinary catheter in a female patient. Which of the
following is an appropriate action for the nurse to take?
A) Cleanse the urinary meatus from back to front.
B) Use a clean, dry cloth to clean the urinary meatus.
C) Insert the catheter without lubrication to minimize discomfort.
D) Place the patient in a supine position with knees slightly apart.
Answer: D) Place the patient in a supine position with knees slightly apart.
Rationale: Positioning the patient in a supine position with knees slightly apart provides optimal
access for catheter insertion.
9. A nurse is caring for a postoperative patient. Which of the following interventions should
the nurse prioritize to prevent atelectasis?
A) Encourage the patient to deep breathe and cough.
B) Administer pain medications as prescribed.
C) Restrict fluid intake to avoid aspiration.
D) Elevate the head of the bed to 45 degrees.
Answer: A) Encourage the patient to deep breathe and cough.
Rationale: Deep breathing and coughing exercises help prevent atelectasis by promoting lung
expansion and clearing secretions.
10. A nurse is assessing a patient who is experiencing a myocardial infarction. Which of the
following findings should the nurse expect?
A) Hypotension and bradycardia
B) Shortness of breath and chest pain
C) Hypertension and bradycardia
D) Nausea and diaphoresis
Answer: B) Shortness of breath and chest pain
Rationale: Common symptoms of myocardial infarction include chest pain, shortness of breath,
nausea, and diaphoresis.
