1. Which of the following is the primary purpose of hand hygiene in a healthcare
setting?
A. To prevent the spread of infection
B. To promote client comfort
C. To reduce the need for gloves
D. To maintain the appearance of the nurse
Answer: A. To prevent the spread of infection
Rationale: Hand hygiene is the most important measure to prevent the transmission of infections
in healthcare settings.
2. A nurse is caring for a client with pneumonia. What should the nurse monitor
most closely for this client?
A. Blood pressure
B. Oxygen saturation
C. Urine output
D. Bowel sounds
Answer: B. Oxygen saturation
Rationale: Pneumonia can impair lung function and oxygen exchange, so monitoring oxygen
saturation is critical.
3. Which of the following is a sign of a possible allergic reaction to a medication?
A. Increased heart rate
B. Nausea and vomiting
C. Difficulty breathing
D. Constipation
Answer: C. Difficulty breathing
Rationale: Difficulty breathing is a serious sign of an allergic reaction and may indicate
anaphylaxis, which requires immediate intervention.
,4. What is the first action a nurse should take when a client is experiencing chest
pain?
A. Administer pain medication
B. Place the client in a high Fowler’s position
C. Call the healthcare provider
D. Assess the client’s vital signs
Answer: D. Assess the client’s vital signs
Rationale: Assessing vital signs is crucial for evaluating the severity of the situation and
determining the next steps for intervention.
5. A nurse is caring for a postoperative client. What is the priority assessment for
the nurse to perform in the immediate postoperative period?
A. Wound healing
B. Respiratory status
C. Pain level
D. Bowel function
Answer: B. Respiratory status
Rationale: After surgery, respiratory function is the most critical to monitor due to the risk of
hypoventilation, atelectasis, or aspiration.
6. Which of the following is a priority action for a nurse who observes a client
having a seizure?
A. Administer oxygen
B. Place a bite block in the client's mouth
C. Protect the client from injury
D. Hold the client's arms to prevent movement
Answer: C. Protect the client from injury
Rationale: Ensuring the client’s safety by preventing injury during a seizure is the priority. The
nurse should not attempt to restrain the client or place objects in their mouth.
, 7. A nurse is preparing to administer a medication to a client. What is the first
action the nurse should take?
A. Confirm the client’s identity
B. Check the medication order
C. Prepare the medication
D. Educate the client about the medication
Answer: A. Confirm the client’s identity
Rationale: Verifying the client’s identity using two identifiers (such as name and date of birth)
is essential to prevent medication errors.
8. Which of the following is an example of a non-verbal communication method?
A. Using a stethoscope
B. Making eye contact
C. Giving a written explanation
D. Speaking slowly
Answer: B. Making eye contact
Rationale: Non-verbal communication includes gestures, facial expressions, body language, and
eye contact, which convey messages without spoken words.
9. A nurse is caring for a client who is receiving chemotherapy. Which of the
following interventions should be included in the client’s care plan to prevent
infection?
A. Administer antipyretics regularly
B. Restrict visitors to immediate family
C. Monitor the client's white blood cell count
D. Limit fluid intake to 1 liter per day
Answer: C. Monitor the client's white blood cell count
Rationale: Chemotherapy can suppress the immune system, so monitoring the white blood cell
count is essential to assess the client’s risk for infection.
setting?
A. To prevent the spread of infection
B. To promote client comfort
C. To reduce the need for gloves
D. To maintain the appearance of the nurse
Answer: A. To prevent the spread of infection
Rationale: Hand hygiene is the most important measure to prevent the transmission of infections
in healthcare settings.
2. A nurse is caring for a client with pneumonia. What should the nurse monitor
most closely for this client?
A. Blood pressure
B. Oxygen saturation
C. Urine output
D. Bowel sounds
Answer: B. Oxygen saturation
Rationale: Pneumonia can impair lung function and oxygen exchange, so monitoring oxygen
saturation is critical.
3. Which of the following is a sign of a possible allergic reaction to a medication?
A. Increased heart rate
B. Nausea and vomiting
C. Difficulty breathing
D. Constipation
Answer: C. Difficulty breathing
Rationale: Difficulty breathing is a serious sign of an allergic reaction and may indicate
anaphylaxis, which requires immediate intervention.
,4. What is the first action a nurse should take when a client is experiencing chest
pain?
A. Administer pain medication
B. Place the client in a high Fowler’s position
C. Call the healthcare provider
D. Assess the client’s vital signs
Answer: D. Assess the client’s vital signs
Rationale: Assessing vital signs is crucial for evaluating the severity of the situation and
determining the next steps for intervention.
5. A nurse is caring for a postoperative client. What is the priority assessment for
the nurse to perform in the immediate postoperative period?
A. Wound healing
B. Respiratory status
C. Pain level
D. Bowel function
Answer: B. Respiratory status
Rationale: After surgery, respiratory function is the most critical to monitor due to the risk of
hypoventilation, atelectasis, or aspiration.
6. Which of the following is a priority action for a nurse who observes a client
having a seizure?
A. Administer oxygen
B. Place a bite block in the client's mouth
C. Protect the client from injury
D. Hold the client's arms to prevent movement
Answer: C. Protect the client from injury
Rationale: Ensuring the client’s safety by preventing injury during a seizure is the priority. The
nurse should not attempt to restrain the client or place objects in their mouth.
, 7. A nurse is preparing to administer a medication to a client. What is the first
action the nurse should take?
A. Confirm the client’s identity
B. Check the medication order
C. Prepare the medication
D. Educate the client about the medication
Answer: A. Confirm the client’s identity
Rationale: Verifying the client’s identity using two identifiers (such as name and date of birth)
is essential to prevent medication errors.
8. Which of the following is an example of a non-verbal communication method?
A. Using a stethoscope
B. Making eye contact
C. Giving a written explanation
D. Speaking slowly
Answer: B. Making eye contact
Rationale: Non-verbal communication includes gestures, facial expressions, body language, and
eye contact, which convey messages without spoken words.
9. A nurse is caring for a client who is receiving chemotherapy. Which of the
following interventions should be included in the client’s care plan to prevent
infection?
A. Administer antipyretics regularly
B. Restrict visitors to immediate family
C. Monitor the client's white blood cell count
D. Limit fluid intake to 1 liter per day
Answer: C. Monitor the client's white blood cell count
Rationale: Chemotherapy can suppress the immune system, so monitoring the white blood cell
count is essential to assess the client’s risk for infection.
