1. Question: Which nursing action is most appropriate when caring for a client with a
nasogastric tube?
o A. Assess the tube placement every shift.
o B. Secure the tube to the client’s gown with tape.
o C. Change the tube feeding formula every 4 hours.
o D. Irrigate the tube with 10 mL of sterile water every 2 hours.
Answer: A. Assess the tube placement every shift.
Rationale: Regular assessment of nasogastric tube placement helps prevent
complications such as aspiration and ensures correct placement for effective enteral
feeding.
2. Question: A client with heart failure is prescribed furosemide (Lasix). Which finding
indicates the medication is effective?
o A. Increased blood pressure.
o B. Decreased urine output.
o C. Weight gain.
o D. Decreased edema.
Answer: D. Decreased edema.
Rationale: Furosemide is a diuretic used to decrease fluid volume, which should result in
decreased edema as a sign of effectiveness.
3. Question: During a physical assessment, the nurse observes that a client has an irregular
heart rhythm with no palpable pulse. What action should the nurse take first?
o A. Administer oxygen.
o B. Start chest compressions.
o C. Prepare to defibrillate.
o D. Assess for breathing.
Answer: B. Start chest compressions.
Rationale: Absence of a palpable pulse indicates cardiac arrest, requiring immediate
initiation of chest compressions to maintain perfusion.
4. Question: When administering heparin subcutaneously, the nurse should:
o A. Massage the injection site after administration.
o B. Inject the medication rapidly.
o C. Use a 25-gauge needle.
o D. Avoid aspirating before injection.
Answer: D. Avoid aspirating before injection.
, Rationale: Aspirating can cause trauma and bleeding. It is unnecessary with
subcutaneous injections, which are typically administered using a small gauge needle.
5. Question: A client with chronic obstructive pulmonary disease (COPD) is prescribed
oxygen therapy. What is a priority nursing intervention?
o A. Administer oxygen at 2 L/min via nasal cannula.
o B. Place the client in a supine position.
o C. Encourage deep breathing exercises every 2 hours.
o D. Monitor oxygen saturation continuously.
Answer: D. Monitor oxygen saturation continuously.
Rationale: Continuous monitoring of oxygen saturation is essential to assess the
effectiveness of oxygen therapy and prevent complications such as hypoxia or oxygen
toxicity.
6. Question: Which client is at highest risk for impaired skin integrity?
o A. A client with a body mass index (BMI) of 25.
o B. A client who is bedridden with fecal incontinence.
o C. A client who walks independently.
o D. A client who has well-controlled diabetes mellitus.
Answer: B. A client who is bedridden with fecal incontinence.
Rationale: Immobility combined with fecal incontinence increases the risk of pressure
ulcers due to prolonged pressure and moisture on the skin.
7. Question: The nurse is caring for a client receiving a blood transfusion. The client
develops sudden dyspnea, chest pain, and hypotension. What action should the nurse take
first?
o A. Stop the transfusion.
o B. Administer oxygen.
o C. Check vital signs.
o D. Notify the healthcare provider.
Answer: A. Stop the transfusion.
Rationale: Symptoms suggest a transfusion reaction, requiring immediate cessation of
the transfusion to prevent further complications.
8. Question: A client is receiving continuous enteral feeding through a nasogastric tube.
Which assessment finding indicates a need for intervention?
o A. Gastric residual volume of 20 mL.
o B. Abdominal distention and discomfort.
o C. Absence of bowel sounds.
o D. Clear, yellow drainage from the tube.
nasogastric tube?
o A. Assess the tube placement every shift.
o B. Secure the tube to the client’s gown with tape.
o C. Change the tube feeding formula every 4 hours.
o D. Irrigate the tube with 10 mL of sterile water every 2 hours.
Answer: A. Assess the tube placement every shift.
Rationale: Regular assessment of nasogastric tube placement helps prevent
complications such as aspiration and ensures correct placement for effective enteral
feeding.
2. Question: A client with heart failure is prescribed furosemide (Lasix). Which finding
indicates the medication is effective?
o A. Increased blood pressure.
o B. Decreased urine output.
o C. Weight gain.
o D. Decreased edema.
Answer: D. Decreased edema.
Rationale: Furosemide is a diuretic used to decrease fluid volume, which should result in
decreased edema as a sign of effectiveness.
3. Question: During a physical assessment, the nurse observes that a client has an irregular
heart rhythm with no palpable pulse. What action should the nurse take first?
o A. Administer oxygen.
o B. Start chest compressions.
o C. Prepare to defibrillate.
o D. Assess for breathing.
Answer: B. Start chest compressions.
Rationale: Absence of a palpable pulse indicates cardiac arrest, requiring immediate
initiation of chest compressions to maintain perfusion.
4. Question: When administering heparin subcutaneously, the nurse should:
o A. Massage the injection site after administration.
o B. Inject the medication rapidly.
o C. Use a 25-gauge needle.
o D. Avoid aspirating before injection.
Answer: D. Avoid aspirating before injection.
, Rationale: Aspirating can cause trauma and bleeding. It is unnecessary with
subcutaneous injections, which are typically administered using a small gauge needle.
5. Question: A client with chronic obstructive pulmonary disease (COPD) is prescribed
oxygen therapy. What is a priority nursing intervention?
o A. Administer oxygen at 2 L/min via nasal cannula.
o B. Place the client in a supine position.
o C. Encourage deep breathing exercises every 2 hours.
o D. Monitor oxygen saturation continuously.
Answer: D. Monitor oxygen saturation continuously.
Rationale: Continuous monitoring of oxygen saturation is essential to assess the
effectiveness of oxygen therapy and prevent complications such as hypoxia or oxygen
toxicity.
6. Question: Which client is at highest risk for impaired skin integrity?
o A. A client with a body mass index (BMI) of 25.
o B. A client who is bedridden with fecal incontinence.
o C. A client who walks independently.
o D. A client who has well-controlled diabetes mellitus.
Answer: B. A client who is bedridden with fecal incontinence.
Rationale: Immobility combined with fecal incontinence increases the risk of pressure
ulcers due to prolonged pressure and moisture on the skin.
7. Question: The nurse is caring for a client receiving a blood transfusion. The client
develops sudden dyspnea, chest pain, and hypotension. What action should the nurse take
first?
o A. Stop the transfusion.
o B. Administer oxygen.
o C. Check vital signs.
o D. Notify the healthcare provider.
Answer: A. Stop the transfusion.
Rationale: Symptoms suggest a transfusion reaction, requiring immediate cessation of
the transfusion to prevent further complications.
8. Question: A client is receiving continuous enteral feeding through a nasogastric tube.
Which assessment finding indicates a need for intervention?
o A. Gastric residual volume of 20 mL.
o B. Abdominal distention and discomfort.
o C. Absence of bowel sounds.
o D. Clear, yellow drainage from the tube.
