1. Which of the following actions by the nurse is the best way to prevent the
spread of infection?
A. Wearing gloves during patient care
B. Performing hand hygiene before and after patient care
C. Using antimicrobial wipes to clean the environment
D. Administering antibiotics to patients with infections
Answer: B. Performing hand hygiene before and after patient care
Rationale: Hand hygiene is the single most effective way to prevent the transmission of
infection. It should be performed before and after patient care to prevent cross-contamination.
2. The nurse is preparing to administer a medication. Which action is most
important to ensure the right drug is given to the right patient?
A. Ask the patient’s name and check their identification band
B. Compare the medication to the physician’s order
C. Ask the patient if they are allergic to the medication
D. Check the expiration date of the medication
Answer: A. Ask the patient’s name and check their identification band
Rationale: Identifying the patient correctly is the most important step in ensuring the right
medication is administered to the right patient. This prevents medication errors.
3. A nurse is assessing a patient’s vital signs. Which of the following vital sign
measurements would be considered abnormal for an adult patient?
A. Temperature of 98.7°F (37.1°C)
B. Respiratory rate of 12 breaths per minute
C. Blood pressure of 160/98 mm Hg
D. Heart rate of 80 beats per minute
Answer: C. Blood pressure of 160/98 mm Hg
Rationale: A blood pressure of 160/98 mm Hg is considered high and indicates hypertension.
Normal blood pressure for an adult is generally less than 120/80 mm Hg.
,4. The nurse is teaching a client how to use a metered-dose inhaler (MDI). What
is the most important instruction to give the client?
A. Inhale deeply after activating the inhaler
B. Shake the inhaler before each use
C. Use the inhaler with a spacer for better absorption
D. Hold your breath for 10 seconds after inhaling
Answer: B. Shake the inhaler before each use
Rationale: Shaking the inhaler ensures that the medication is properly mixed and delivered
effectively. It is also important to use a spacer and hold the breath after inhalation, but shaking
the device is critical for accurate delivery.
5. A nurse is caring for a patient who has had a stroke and is experiencing
dysphagia. Which of the following actions should the nurse take first?
A. Provide a soft diet
B. Consult with a speech therapist
C. Keep the patient in a supine position
D. Offer thickened liquids
Answer: B. Consult with a speech therapist
Rationale: A speech therapist should assess the patient for dysphagia (difficulty swallowing) to
ensure the patient is safe to eat and drink. This will help guide further interventions.
6. When assessing a patient's pain, the nurse asks the patient to rate their pain on
a scale from 0 to 10. Which of the following is the best rationale for using this
scale?
A. It is easy for the patient to understand
B. It allows for quick assessment of pain
C. It helps determine the location of the pain
D. It ensures accurate measurement of pain levels
Answer: A. It is easy for the patient to understand
Rationale: The 0 to 10 pain scale is widely used because it is simple for patients to understand
and provides a subjective measure of pain intensity.
, 7. The nurse is caring for a patient who has been diagnosed with pneumonia. The
nurse notes that the patient’s oxygen saturation level is 88%. What should the
nurse do first?
A. Place the patient in a high-Fowler’s position
B. Administer oxygen as ordered
C. Encourage deep breathing exercises
D. Document the finding and continue to monitor the patient
Answer: B. Administer oxygen as ordered
Rationale: An oxygen saturation level of 88% is considered low and indicates that the patient
needs supplemental oxygen to improve oxygenation.
8. A nurse is providing discharge instructions to a patient who had surgery.
Which of the following statements by the patient indicates understanding of the
instructions?
A. "I can resume my normal activities as soon as I feel better."
B. "I will call my doctor if I experience fever over 101°F (38.3°C)."
C. "I should avoid all physical activity for the next 2 weeks."
D. "It’s normal for my wound to be red and swollen for a few days."
Answer: B. "I will call my doctor if I experience fever over 101°F (38.3°C).”
Rationale: A fever over 101°F may indicate infection and should be reported to the physician
immediately. The other statements are not entirely accurate or appropriate for post-surgical
recovery.
9. The nurse is teaching a patient about insulin administration. Which of the
following statements indicates that the patient understands the teaching?
A. "I should inject the insulin into the muscle for faster absorption."
B. "I should rotate injection sites to prevent tissue damage."
C. "I should always inject insulin into the abdomen only."
D. "I will increase my insulin dose when my blood sugar is high."
Answer: B. "I should rotate injection sites to prevent tissue damage."
spread of infection?
A. Wearing gloves during patient care
B. Performing hand hygiene before and after patient care
C. Using antimicrobial wipes to clean the environment
D. Administering antibiotics to patients with infections
Answer: B. Performing hand hygiene before and after patient care
Rationale: Hand hygiene is the single most effective way to prevent the transmission of
infection. It should be performed before and after patient care to prevent cross-contamination.
2. The nurse is preparing to administer a medication. Which action is most
important to ensure the right drug is given to the right patient?
A. Ask the patient’s name and check their identification band
B. Compare the medication to the physician’s order
C. Ask the patient if they are allergic to the medication
D. Check the expiration date of the medication
Answer: A. Ask the patient’s name and check their identification band
Rationale: Identifying the patient correctly is the most important step in ensuring the right
medication is administered to the right patient. This prevents medication errors.
3. A nurse is assessing a patient’s vital signs. Which of the following vital sign
measurements would be considered abnormal for an adult patient?
A. Temperature of 98.7°F (37.1°C)
B. Respiratory rate of 12 breaths per minute
C. Blood pressure of 160/98 mm Hg
D. Heart rate of 80 beats per minute
Answer: C. Blood pressure of 160/98 mm Hg
Rationale: A blood pressure of 160/98 mm Hg is considered high and indicates hypertension.
Normal blood pressure for an adult is generally less than 120/80 mm Hg.
,4. The nurse is teaching a client how to use a metered-dose inhaler (MDI). What
is the most important instruction to give the client?
A. Inhale deeply after activating the inhaler
B. Shake the inhaler before each use
C. Use the inhaler with a spacer for better absorption
D. Hold your breath for 10 seconds after inhaling
Answer: B. Shake the inhaler before each use
Rationale: Shaking the inhaler ensures that the medication is properly mixed and delivered
effectively. It is also important to use a spacer and hold the breath after inhalation, but shaking
the device is critical for accurate delivery.
5. A nurse is caring for a patient who has had a stroke and is experiencing
dysphagia. Which of the following actions should the nurse take first?
A. Provide a soft diet
B. Consult with a speech therapist
C. Keep the patient in a supine position
D. Offer thickened liquids
Answer: B. Consult with a speech therapist
Rationale: A speech therapist should assess the patient for dysphagia (difficulty swallowing) to
ensure the patient is safe to eat and drink. This will help guide further interventions.
6. When assessing a patient's pain, the nurse asks the patient to rate their pain on
a scale from 0 to 10. Which of the following is the best rationale for using this
scale?
A. It is easy for the patient to understand
B. It allows for quick assessment of pain
C. It helps determine the location of the pain
D. It ensures accurate measurement of pain levels
Answer: A. It is easy for the patient to understand
Rationale: The 0 to 10 pain scale is widely used because it is simple for patients to understand
and provides a subjective measure of pain intensity.
, 7. The nurse is caring for a patient who has been diagnosed with pneumonia. The
nurse notes that the patient’s oxygen saturation level is 88%. What should the
nurse do first?
A. Place the patient in a high-Fowler’s position
B. Administer oxygen as ordered
C. Encourage deep breathing exercises
D. Document the finding and continue to monitor the patient
Answer: B. Administer oxygen as ordered
Rationale: An oxygen saturation level of 88% is considered low and indicates that the patient
needs supplemental oxygen to improve oxygenation.
8. A nurse is providing discharge instructions to a patient who had surgery.
Which of the following statements by the patient indicates understanding of the
instructions?
A. "I can resume my normal activities as soon as I feel better."
B. "I will call my doctor if I experience fever over 101°F (38.3°C)."
C. "I should avoid all physical activity for the next 2 weeks."
D. "It’s normal for my wound to be red and swollen for a few days."
Answer: B. "I will call my doctor if I experience fever over 101°F (38.3°C).”
Rationale: A fever over 101°F may indicate infection and should be reported to the physician
immediately. The other statements are not entirely accurate or appropriate for post-surgical
recovery.
9. The nurse is teaching a patient about insulin administration. Which of the
following statements indicates that the patient understands the teaching?
A. "I should inject the insulin into the muscle for faster absorption."
B. "I should rotate injection sites to prevent tissue damage."
C. "I should always inject insulin into the abdomen only."
D. "I will increase my insulin dose when my blood sugar is high."
Answer: B. "I should rotate injection sites to prevent tissue damage."
