1. Which of the following is the primary goal of a nurse when providing patient
care?
A. To perform tasks quickly
B. To maintain patient safety
C. To educate the family
D. To complete the assessment
Answer: B. To maintain patient safety
Rationale: The primary goal of nursing is always to maintain patient safety, ensuring the well-
being of the patient during all interventions and care processes.
2. What is the most important factor to consider when applying a restraint to a
patient?
A. The patient's comfort
B. The healthcare provider’s orders
C. The patient's dignity
D. The patient's mobility
Answer: B. The healthcare provider’s orders
Rationale: Restraints must only be applied following a healthcare provider’s orders. Nursing
staff are responsible for ensuring that restraints are used in compliance with these guidelines and
protocols.
3. The nurse is assessing a patient who is experiencing shortness of breath.
Which of the following actions should the nurse take first?
A. Administer supplemental oxygen
B. Ask the patient to lie down
C. Perform a full respiratory assessment
D. Notify the healthcare provider
Answer: C. Perform a full respiratory assessment
Rationale: The nurse should perform a full respiratory assessment to determine the cause and
severity of the shortness of breath, which will guide appropriate interventions.
4. A patient has been prescribed an analgesic medication. The nurse notes that
the patient’s blood pressure is 90/60 mmHg. What is the nurse's priority action?
,A. Administer the analgesic medication as prescribed
B. Notify the healthcare provider
C. Withhold the medication and assess the patient further
D. Increase the dose of the medication
Answer: C. Withhold the medication and assess the patient further
Rationale: The nurse should withhold the medication and assess the patient further, especially
since the patient’s blood pressure is low. The healthcare provider may need to adjust the dosage
or choose an alternative medication.
5. The nurse is teaching a patient about diabetes mellitus management. Which
statement by the patient indicates a need for further teaching?
A. "I need to monitor my blood glucose levels regularly."
B. "I can eat whatever I want as long as I take insulin."
C. "I should exercise regularly to help control my blood sugar."
D. "I will avoid alcohol because it can affect my blood sugar."
Answer: B. "I can eat whatever I want as long as I take insulin."
Rationale: Insulin therapy does not allow a patient with diabetes to eat anything without
considering the impact on blood glucose levels. The patient needs to follow a balanced diet and
monitor carbohydrate intake.
6. A nurse is caring for a patient who is post-operative after a laparotomy. Which
of the following is a priority nursing intervention for this patient?
A. Monitor vital signs every 4 hours
B. Encourage deep breathing and coughing exercises
C. Provide pain medication every 4 hours
D. Administer antibiotics as prescribed
Answer: B. Encourage deep breathing and coughing exercises
Rationale: After surgery, deep breathing and coughing exercises help prevent complications
such as atelectasis and pneumonia by promoting lung expansion and clearing secretions.
7. What is the most important action for the nurse to take when caring for a
patient with a central venous catheter?
, A. Change the dressing on the catheter site every 72 hours
B. Use strict aseptic technique when accessing the catheter
C. Flush the catheter with saline only
D. Ensure the catheter is positioned in the left subclavian vein
Answer: B. Use strict aseptic technique when accessing the catheter
Rationale: Strict aseptic technique is crucial to prevent infection when accessing central venous
catheters.
8. A nurse is caring for a patient who is receiving a blood transfusion. Which of
the following is the first action the nurse should take if the patient begins to
experience chills and fever?
A. Discontinue the transfusion and notify the healthcare provider
B. Slow the transfusion rate and administer acetaminophen
C. Administer a dose of antihistamine
D. Increase the rate of the transfusion
Answer: A. Discontinue the transfusion and notify the healthcare provider
Rationale: Chills and fever are signs of a potential transfusion reaction. The nurse should
immediately discontinue the transfusion to prevent further complications and notify the
healthcare provider.
9. A nurse is caring for a patient who is at risk for developing a pressure ulcer.
Which of the following interventions is most effective in preventing this
complication?
A. Repositioning the patient every 2 hours
B. Applying a heat pack to the skin
C. Ensuring the patient remains in a supine position
D. Offering the patient a high-protein diet
Answer: A. Repositioning the patient every 2 hours
Rationale: Repositioning patients every 2 hours helps relieve pressure on areas vulnerable to
skin breakdown, preventing the development of pressure ulcers.
10. A nurse is caring for a patient who is receiving intravenous (IV) fluids.
Which of the following findings should the nurse report immediately to the
healthcare provider?
care?
A. To perform tasks quickly
B. To maintain patient safety
C. To educate the family
D. To complete the assessment
Answer: B. To maintain patient safety
Rationale: The primary goal of nursing is always to maintain patient safety, ensuring the well-
being of the patient during all interventions and care processes.
2. What is the most important factor to consider when applying a restraint to a
patient?
A. The patient's comfort
B. The healthcare provider’s orders
C. The patient's dignity
D. The patient's mobility
Answer: B. The healthcare provider’s orders
Rationale: Restraints must only be applied following a healthcare provider’s orders. Nursing
staff are responsible for ensuring that restraints are used in compliance with these guidelines and
protocols.
3. The nurse is assessing a patient who is experiencing shortness of breath.
Which of the following actions should the nurse take first?
A. Administer supplemental oxygen
B. Ask the patient to lie down
C. Perform a full respiratory assessment
D. Notify the healthcare provider
Answer: C. Perform a full respiratory assessment
Rationale: The nurse should perform a full respiratory assessment to determine the cause and
severity of the shortness of breath, which will guide appropriate interventions.
4. A patient has been prescribed an analgesic medication. The nurse notes that
the patient’s blood pressure is 90/60 mmHg. What is the nurse's priority action?
,A. Administer the analgesic medication as prescribed
B. Notify the healthcare provider
C. Withhold the medication and assess the patient further
D. Increase the dose of the medication
Answer: C. Withhold the medication and assess the patient further
Rationale: The nurse should withhold the medication and assess the patient further, especially
since the patient’s blood pressure is low. The healthcare provider may need to adjust the dosage
or choose an alternative medication.
5. The nurse is teaching a patient about diabetes mellitus management. Which
statement by the patient indicates a need for further teaching?
A. "I need to monitor my blood glucose levels regularly."
B. "I can eat whatever I want as long as I take insulin."
C. "I should exercise regularly to help control my blood sugar."
D. "I will avoid alcohol because it can affect my blood sugar."
Answer: B. "I can eat whatever I want as long as I take insulin."
Rationale: Insulin therapy does not allow a patient with diabetes to eat anything without
considering the impact on blood glucose levels. The patient needs to follow a balanced diet and
monitor carbohydrate intake.
6. A nurse is caring for a patient who is post-operative after a laparotomy. Which
of the following is a priority nursing intervention for this patient?
A. Monitor vital signs every 4 hours
B. Encourage deep breathing and coughing exercises
C. Provide pain medication every 4 hours
D. Administer antibiotics as prescribed
Answer: B. Encourage deep breathing and coughing exercises
Rationale: After surgery, deep breathing and coughing exercises help prevent complications
such as atelectasis and pneumonia by promoting lung expansion and clearing secretions.
7. What is the most important action for the nurse to take when caring for a
patient with a central venous catheter?
, A. Change the dressing on the catheter site every 72 hours
B. Use strict aseptic technique when accessing the catheter
C. Flush the catheter with saline only
D. Ensure the catheter is positioned in the left subclavian vein
Answer: B. Use strict aseptic technique when accessing the catheter
Rationale: Strict aseptic technique is crucial to prevent infection when accessing central venous
catheters.
8. A nurse is caring for a patient who is receiving a blood transfusion. Which of
the following is the first action the nurse should take if the patient begins to
experience chills and fever?
A. Discontinue the transfusion and notify the healthcare provider
B. Slow the transfusion rate and administer acetaminophen
C. Administer a dose of antihistamine
D. Increase the rate of the transfusion
Answer: A. Discontinue the transfusion and notify the healthcare provider
Rationale: Chills and fever are signs of a potential transfusion reaction. The nurse should
immediately discontinue the transfusion to prevent further complications and notify the
healthcare provider.
9. A nurse is caring for a patient who is at risk for developing a pressure ulcer.
Which of the following interventions is most effective in preventing this
complication?
A. Repositioning the patient every 2 hours
B. Applying a heat pack to the skin
C. Ensuring the patient remains in a supine position
D. Offering the patient a high-protein diet
Answer: A. Repositioning the patient every 2 hours
Rationale: Repositioning patients every 2 hours helps relieve pressure on areas vulnerable to
skin breakdown, preventing the development of pressure ulcers.
10. A nurse is caring for a patient who is receiving intravenous (IV) fluids.
Which of the following findings should the nurse report immediately to the
healthcare provider?
