1. Which of the following is the priority nursing action when caring for a patient
experiencing respiratory distress?
a) Administer oxygen
b) Assess the patient's vital signs
c) Notify the physician
d) Encourage the patient to cough deeply
Answer: a) Administer oxygen
Rationale: In respiratory distress, the priority is to ensure the patient has adequate oxygenation.
Administering oxygen helps improve the patient’s oxygen saturation, which is critical in this
situation.
2. A nurse is preparing a patient for a lumbar puncture. Which of the following
positions should the nurse instruct the patient to assume during the procedure?
a) Supine
b) Lateral recumbent
c) Prone
d) Fowler's position
Answer: b) Lateral recumbent
Rationale: The lateral recumbent (side-lying) position helps open the intervertebral spaces for
better access to the cerebrospinal fluid during a lumbar puncture.
3. A nurse is caring for a client with a chest tube. Which of the following findings
should the nurse report immediately to the healthcare provider?
a) Drainage of 50 mL of fluid in the last hour
b) Constant bubbling in the water-seal chamber
c) The chest tube is connected to suction
d) The patient is reporting mild discomfort at the insertion site
Answer: b) Constant bubbling in the water-seal chamber
Rationale: Constant bubbling in the water-seal chamber can indicate an air leak, which may
require immediate intervention to prevent further complications.
4. The nurse is preparing to administer an intramuscular injection. Which of the
following is the appropriate needle size for this procedure?
, a) 25 gauge, 5/8 inch
b) 21 gauge, 1 inch
c) 22 gauge, 1.5 inch
d) 18 gauge, 1 inch
Answer: c) 22 gauge, 1.5 inch
Rationale: A 22-gauge, 1.5-inch needle is typically used for intramuscular injections, allowing
for adequate penetration into muscle tissue.
5. A patient is receiving morphine for postoperative pain. Which of the following
is the most important assessment for the nurse to perform?
a) Monitor the patient's level of consciousness
b) Assess the patient's pain level
c) Monitor the patient's urinary output
d) Evaluate the patient's bowel sounds
Answer: a) Monitor the patient's level of consciousness
Rationale: Morphine, an opioid, can cause sedation and respiratory depression. Monitoring the
patient's level of consciousness helps detect any early signs of opioid overdose or adverse
effects.
6. The nurse is caring for a client who has a pressure ulcer. Which of the
following interventions should the nurse prioritize?
a) Encourage the client to eat a high-protein diet
b) Administer prescribed antibiotics
c) Apply a dry dressing to the ulcer
d) Perform a complete blood count (CBC)
Answer: a) Encourage the client to eat a high-protein diet
Rationale: Adequate nutrition, including protein, is essential for wound healing. A high-protein
diet promotes tissue repair and helps prevent further skin breakdown.
7. The nurse is providing teaching for a client with hypertension. Which of the
following statements indicates the need for further teaching?
a) “I should monitor my blood pressure regularly.”
b) “I can stop taking my medication when my blood pressure is normal.”
experiencing respiratory distress?
a) Administer oxygen
b) Assess the patient's vital signs
c) Notify the physician
d) Encourage the patient to cough deeply
Answer: a) Administer oxygen
Rationale: In respiratory distress, the priority is to ensure the patient has adequate oxygenation.
Administering oxygen helps improve the patient’s oxygen saturation, which is critical in this
situation.
2. A nurse is preparing a patient for a lumbar puncture. Which of the following
positions should the nurse instruct the patient to assume during the procedure?
a) Supine
b) Lateral recumbent
c) Prone
d) Fowler's position
Answer: b) Lateral recumbent
Rationale: The lateral recumbent (side-lying) position helps open the intervertebral spaces for
better access to the cerebrospinal fluid during a lumbar puncture.
3. A nurse is caring for a client with a chest tube. Which of the following findings
should the nurse report immediately to the healthcare provider?
a) Drainage of 50 mL of fluid in the last hour
b) Constant bubbling in the water-seal chamber
c) The chest tube is connected to suction
d) The patient is reporting mild discomfort at the insertion site
Answer: b) Constant bubbling in the water-seal chamber
Rationale: Constant bubbling in the water-seal chamber can indicate an air leak, which may
require immediate intervention to prevent further complications.
4. The nurse is preparing to administer an intramuscular injection. Which of the
following is the appropriate needle size for this procedure?
, a) 25 gauge, 5/8 inch
b) 21 gauge, 1 inch
c) 22 gauge, 1.5 inch
d) 18 gauge, 1 inch
Answer: c) 22 gauge, 1.5 inch
Rationale: A 22-gauge, 1.5-inch needle is typically used for intramuscular injections, allowing
for adequate penetration into muscle tissue.
5. A patient is receiving morphine for postoperative pain. Which of the following
is the most important assessment for the nurse to perform?
a) Monitor the patient's level of consciousness
b) Assess the patient's pain level
c) Monitor the patient's urinary output
d) Evaluate the patient's bowel sounds
Answer: a) Monitor the patient's level of consciousness
Rationale: Morphine, an opioid, can cause sedation and respiratory depression. Monitoring the
patient's level of consciousness helps detect any early signs of opioid overdose or adverse
effects.
6. The nurse is caring for a client who has a pressure ulcer. Which of the
following interventions should the nurse prioritize?
a) Encourage the client to eat a high-protein diet
b) Administer prescribed antibiotics
c) Apply a dry dressing to the ulcer
d) Perform a complete blood count (CBC)
Answer: a) Encourage the client to eat a high-protein diet
Rationale: Adequate nutrition, including protein, is essential for wound healing. A high-protein
diet promotes tissue repair and helps prevent further skin breakdown.
7. The nurse is providing teaching for a client with hypertension. Which of the
following statements indicates the need for further teaching?
a) “I should monitor my blood pressure regularly.”
b) “I can stop taking my medication when my blood pressure is normal.”
