1. Which of the following is the primary purpose of a nursing assessment?
A. To establish a therapeutic relationship with the patient
B. To collect data for clinical decision-making
C. To diagnose the patient's condition
D. To administer medication
Answer: B. To collect data for clinical decision-making
Rationale: The primary purpose of a nursing assessment is to gather data that will guide clinical
decision-making for patient care.
2. The nurse is teaching a patient about self-administration of insulin. Which of
the following would be an appropriate learning goal?
A. The patient will administer insulin 30 minutes after meals
B. The patient will demonstrate correct insulin administration technique
C. The patient will understand the risk of hypoglycemia
D. The patient will be able to draw insulin in a syringe
Answer: B. The patient will demonstrate correct insulin administration technique
Rationale: The goal should focus on the patient's ability to perform the desired skill accurately.
3. The nurse is caring for a client with a urinary catheter. Which of the following
actions is most important to prevent a urinary tract infection (UTI)?
A. Clean the catheter site with soap and water daily
B. Secure the catheter to the leg with a strap
C. Ensure that the drainage bag is below the level of the bladder
D. Change the catheter every 48 hours
Answer: C. Ensure that the drainage bag is below the level of the bladder
Rationale: Keeping the drainage bag below the level of the bladder helps prevent backflow of
urine, which could introduce bacteria into the urinary tract.
4. A nurse is assessing a patient’s vital signs. Which of the following findings
should the nurse report to the healthcare provider immediately?
A. Blood pressure 140/90 mmHg
B. Heart rate 120 beats per minute
,C. Temperature 99.1°F (37.3°C)
D. Respiratory rate 18 breaths per minute
Answer: B. Heart rate 120 beats per minute
Rationale: A heart rate of 120 beats per minute is considered tachycardia and may indicate an
underlying issue that requires medical evaluation.
5. The nurse is teaching a client how to perform deep breathing exercises. Which
of the following actions should the nurse recommend to promote relaxation
during the exercise?
A. Sit with legs crossed
B. Inhale rapidly and deeply
C. Exhale through pursed lips
D. Keep the eyes open during the exercise
Answer: C. Exhale through pursed lips
Rationale: Pursed lip breathing promotes relaxation and helps to slow the exhalation, which
improves ventilation.
6. A nurse is caring for a patient with heart failure. Which of the following
findings would indicate worsening heart failure?
A. Weight loss of 2 pounds in 2 days
B. Decreased urine output and swelling in the legs
C. Increased appetite and energy levels
D. Respiratory rate of 14 breaths per minute
Answer: B. Decreased urine output and swelling in the legs
Rationale: These signs suggest fluid retention, which can be a sign of worsening heart failure.
7. A nurse is caring for a patient with a pressure ulcer. Which of the following
interventions is most important to prevent further skin breakdown?
A. Turn the patient every 2 hours
B. Apply a moisture barrier to the skin
C. Provide high-protein meals
D. Use a pressure-relieving mattress
, Answer: D. Use a pressure-relieving mattress
Rationale: A pressure-relieving mattress helps redistribute pressure, reducing the risk of further
skin breakdown.
8. A nurse is caring for a patient with pneumonia. Which of the following
interventions is most important in promoting oxygenation?
A. Place the patient in a supine position
B. Encourage the patient to cough and deep breathe
C. Limit fluid intake to avoid fluid overload
D. Administer sedatives to promote rest
Answer: B. Encourage the patient to cough and deep breathe
Rationale: Coughing and deep breathing help clear the airways, improving oxygenation and
reducing the risk of atelectasis.
9. A nurse is caring for a patient receiving a blood transfusion. Which of the
following actions should the nurse take if the patient develops chills and fever?
A. Continue the transfusion and monitor the patient
B. Stop the transfusion and notify the healthcare provider
C. Administer acetaminophen and resume the transfusion
D. Decrease the transfusion rate and reassess the patient
Answer: B. Stop the transfusion and notify the healthcare provider
Rationale: Chills and fever may indicate an adverse reaction to the transfusion, so it is essential
to stop the transfusion immediately and seek further medical advice.
10. The nurse is preparing to administer a medication to a patient. What is the
first step in the medication administration process?
A. Verify the patient’s identity
B. Check the medication order
C. Assess the patient’s allergies
D. Prepare the medication
Answer: B. Check the medication order
Rationale: The nurse should always begin by reviewing the medication order to ensure it is
accurate and appropriate before proceeding.
A. To establish a therapeutic relationship with the patient
B. To collect data for clinical decision-making
C. To diagnose the patient's condition
D. To administer medication
Answer: B. To collect data for clinical decision-making
Rationale: The primary purpose of a nursing assessment is to gather data that will guide clinical
decision-making for patient care.
2. The nurse is teaching a patient about self-administration of insulin. Which of
the following would be an appropriate learning goal?
A. The patient will administer insulin 30 minutes after meals
B. The patient will demonstrate correct insulin administration technique
C. The patient will understand the risk of hypoglycemia
D. The patient will be able to draw insulin in a syringe
Answer: B. The patient will demonstrate correct insulin administration technique
Rationale: The goal should focus on the patient's ability to perform the desired skill accurately.
3. The nurse is caring for a client with a urinary catheter. Which of the following
actions is most important to prevent a urinary tract infection (UTI)?
A. Clean the catheter site with soap and water daily
B. Secure the catheter to the leg with a strap
C. Ensure that the drainage bag is below the level of the bladder
D. Change the catheter every 48 hours
Answer: C. Ensure that the drainage bag is below the level of the bladder
Rationale: Keeping the drainage bag below the level of the bladder helps prevent backflow of
urine, which could introduce bacteria into the urinary tract.
4. A nurse is assessing a patient’s vital signs. Which of the following findings
should the nurse report to the healthcare provider immediately?
A. Blood pressure 140/90 mmHg
B. Heart rate 120 beats per minute
,C. Temperature 99.1°F (37.3°C)
D. Respiratory rate 18 breaths per minute
Answer: B. Heart rate 120 beats per minute
Rationale: A heart rate of 120 beats per minute is considered tachycardia and may indicate an
underlying issue that requires medical evaluation.
5. The nurse is teaching a client how to perform deep breathing exercises. Which
of the following actions should the nurse recommend to promote relaxation
during the exercise?
A. Sit with legs crossed
B. Inhale rapidly and deeply
C. Exhale through pursed lips
D. Keep the eyes open during the exercise
Answer: C. Exhale through pursed lips
Rationale: Pursed lip breathing promotes relaxation and helps to slow the exhalation, which
improves ventilation.
6. A nurse is caring for a patient with heart failure. Which of the following
findings would indicate worsening heart failure?
A. Weight loss of 2 pounds in 2 days
B. Decreased urine output and swelling in the legs
C. Increased appetite and energy levels
D. Respiratory rate of 14 breaths per minute
Answer: B. Decreased urine output and swelling in the legs
Rationale: These signs suggest fluid retention, which can be a sign of worsening heart failure.
7. A nurse is caring for a patient with a pressure ulcer. Which of the following
interventions is most important to prevent further skin breakdown?
A. Turn the patient every 2 hours
B. Apply a moisture barrier to the skin
C. Provide high-protein meals
D. Use a pressure-relieving mattress
, Answer: D. Use a pressure-relieving mattress
Rationale: A pressure-relieving mattress helps redistribute pressure, reducing the risk of further
skin breakdown.
8. A nurse is caring for a patient with pneumonia. Which of the following
interventions is most important in promoting oxygenation?
A. Place the patient in a supine position
B. Encourage the patient to cough and deep breathe
C. Limit fluid intake to avoid fluid overload
D. Administer sedatives to promote rest
Answer: B. Encourage the patient to cough and deep breathe
Rationale: Coughing and deep breathing help clear the airways, improving oxygenation and
reducing the risk of atelectasis.
9. A nurse is caring for a patient receiving a blood transfusion. Which of the
following actions should the nurse take if the patient develops chills and fever?
A. Continue the transfusion and monitor the patient
B. Stop the transfusion and notify the healthcare provider
C. Administer acetaminophen and resume the transfusion
D. Decrease the transfusion rate and reassess the patient
Answer: B. Stop the transfusion and notify the healthcare provider
Rationale: Chills and fever may indicate an adverse reaction to the transfusion, so it is essential
to stop the transfusion immediately and seek further medical advice.
10. The nurse is preparing to administer a medication to a patient. What is the
first step in the medication administration process?
A. Verify the patient’s identity
B. Check the medication order
C. Assess the patient’s allergies
D. Prepare the medication
Answer: B. Check the medication order
Rationale: The nurse should always begin by reviewing the medication order to ensure it is
accurate and appropriate before proceeding.
