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Q1. A nurse is caring for a client who is immobile following surgery. Which
intervention is the most important to reduce the risk of deep vein thrombosis
(DVT)?
A. Encourage fluid intake of 1 L/day
B. Perform passive range-of-motion exercises
C. Apply sequential compression devices
D. Elevate the head of the bed 45°
Answer: C. Apply sequential compression devices
Rationale: Compression devices promote venous return and are the most effective
DVT prevention strategy. ROM and fluids help, but not as effectively.
Q2. A nurse observes a UAP (unlicensed assistive personnel) preparing to
ambulate a client with a gait belt. Which action by the UAP requires intervention?
A. Placing the belt snugly around the client’s waist
B. Standing slightly behind the client during ambulation
C. Securing the belt over the client’s chest
D. Using the handles to support the client’s balance
Answer: C. Securing the belt over the client’s chest
Rationale: The gait belt must be secured at the waist, never the chest, to prevent
injury.
Q3. A client is prescribed furosemide for hypertension. Which laboratory value
requires immediate reporting?
A. Sodium 139 mEq/L
B. Potassium 2.8 mEq/L
C. Chloride 100 mEq/L
D. Calcium 9.2 mg/dL
Answer: B. Potassium 2.8 mEq/L
Rationale: Hypokalemia is a dangerous side effect of loop diuretics and may cause
dysrhythmias.
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Q4. The nurse is teaching a client about a low-sodium diet. Which food selection
shows correct understanding?
A. Canned vegetable soup
B. Fresh green beans
C. Processed cheese
D. Pickles
Answer: B. Fresh green beans
Rationale: Fresh foods are naturally lower in sodium; canned, processed, and
pickled foods are high in sodium.
Q5. The nurse prepares to insert an indwelling urinary catheter. Which action is
essential to maintain sterility?
A. Place sterile gloves on the over-bed table
B. Lubricate the catheter tip after donning sterile gloves
C. Open the sterile catheter kit using clean gloves
D. Touch the catheter tubing with sterile gloved hands only
Answer: D. Touch the catheter tubing with sterile gloved hands only
Rationale: Maintaining a sterile field prevents infection. Sterile gloves must be
worn when handling the catheter.
Q6. A client is at risk for skin breakdown. Which nursing intervention is most
effective?
A. Massage reddened areas every shift
B. Reposition the client every 2 hours
C. Apply cornstarch to moist skin folds
D. Encourage high-fat meals
Answer: B. Reposition the client every 2 hours
Rationale: Frequent repositioning relieves pressure and is the most important
preventive measure. Massaging reddened areas is contraindicated.
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Q7. A nurse is caring for a client with a NG tube connected to low intermittent
suction. Which finding requires intervention?
A. Clear, green drainage present
B. Oral mucosa dry and cracked
C. Abdominal distention reduced
D. NG tube securely taped
Answer: B. Oral mucosa dry and cracked
Rationale: Suction can cause fluid loss and dryness; frequent oral care is essential
to maintain comfort and prevent complications.
Q8. The nurse prepares to administer digoxin to a client. Which assessment is
priority?
A. Blood pressure
B. Serum sodium level
C. Apical pulse
D. Respiratory rate
Answer: C. Apical pulse
Rationale: Digoxin slows heart rate; if apical pulse <60 bpm, the medication
should be held and provider notified.
Q9. The nurse notes a client has a temperature of 101.8°F (38.8°C). Which action
should be taken first?
A. Administer prescribed antipyretic
B. Encourage oral fluid intake
C. Obtain blood cultures
D. Apply a cooling blanket
Answer: C. Obtain blood cultures
Rationale: Cultures must be obtained before antibiotics or antipyretics to avoid
altering results.
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Q1. A nurse is caring for a client who is immobile following surgery. Which
intervention is the most important to reduce the risk of deep vein thrombosis
(DVT)?
A. Encourage fluid intake of 1 L/day
B. Perform passive range-of-motion exercises
C. Apply sequential compression devices
D. Elevate the head of the bed 45°
Answer: C. Apply sequential compression devices
Rationale: Compression devices promote venous return and are the most effective
DVT prevention strategy. ROM and fluids help, but not as effectively.
Q2. A nurse observes a UAP (unlicensed assistive personnel) preparing to
ambulate a client with a gait belt. Which action by the UAP requires intervention?
A. Placing the belt snugly around the client’s waist
B. Standing slightly behind the client during ambulation
C. Securing the belt over the client’s chest
D. Using the handles to support the client’s balance
Answer: C. Securing the belt over the client’s chest
Rationale: The gait belt must be secured at the waist, never the chest, to prevent
injury.
Q3. A client is prescribed furosemide for hypertension. Which laboratory value
requires immediate reporting?
A. Sodium 139 mEq/L
B. Potassium 2.8 mEq/L
C. Chloride 100 mEq/L
D. Calcium 9.2 mg/dL
Answer: B. Potassium 2.8 mEq/L
Rationale: Hypokalemia is a dangerous side effect of loop diuretics and may cause
dysrhythmias.
,3 | Page
Q4. The nurse is teaching a client about a low-sodium diet. Which food selection
shows correct understanding?
A. Canned vegetable soup
B. Fresh green beans
C. Processed cheese
D. Pickles
Answer: B. Fresh green beans
Rationale: Fresh foods are naturally lower in sodium; canned, processed, and
pickled foods are high in sodium.
Q5. The nurse prepares to insert an indwelling urinary catheter. Which action is
essential to maintain sterility?
A. Place sterile gloves on the over-bed table
B. Lubricate the catheter tip after donning sterile gloves
C. Open the sterile catheter kit using clean gloves
D. Touch the catheter tubing with sterile gloved hands only
Answer: D. Touch the catheter tubing with sterile gloved hands only
Rationale: Maintaining a sterile field prevents infection. Sterile gloves must be
worn when handling the catheter.
Q6. A client is at risk for skin breakdown. Which nursing intervention is most
effective?
A. Massage reddened areas every shift
B. Reposition the client every 2 hours
C. Apply cornstarch to moist skin folds
D. Encourage high-fat meals
Answer: B. Reposition the client every 2 hours
Rationale: Frequent repositioning relieves pressure and is the most important
preventive measure. Massaging reddened areas is contraindicated.
, 4 | Page
Q7. A nurse is caring for a client with a NG tube connected to low intermittent
suction. Which finding requires intervention?
A. Clear, green drainage present
B. Oral mucosa dry and cracked
C. Abdominal distention reduced
D. NG tube securely taped
Answer: B. Oral mucosa dry and cracked
Rationale: Suction can cause fluid loss and dryness; frequent oral care is essential
to maintain comfort and prevent complications.
Q8. The nurse prepares to administer digoxin to a client. Which assessment is
priority?
A. Blood pressure
B. Serum sodium level
C. Apical pulse
D. Respiratory rate
Answer: C. Apical pulse
Rationale: Digoxin slows heart rate; if apical pulse <60 bpm, the medication
should be held and provider notified.
Q9. The nurse notes a client has a temperature of 101.8°F (38.8°C). Which action
should be taken first?
A. Administer prescribed antipyretic
B. Encourage oral fluid intake
C. Obtain blood cultures
D. Apply a cooling blanket
Answer: C. Obtain blood cultures
Rationale: Cultures must be obtained before antibiotics or antipyretics to avoid
altering results.
