ACTUAL EXAM COMPLETE 250 QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY
GRADED A+
Question 1
A nurse is preparing to administer an oral medication to a client. Which of
the following actions should the nurse perform first?
A) Document the medication administration.
B) Identify the client.
C) Open the medication package.
D) Explain the medication to the client.
E) Check the medication expiration date.
Correct Answer: B) Identify the client.
Rationale: According to the "Rights of Medication Administration,"
identifying the client using at least two identifiers is the first and
most critical step to ensure patient safety and prevent medication
errors.
Question 2
A nurse is caring for a client who reports pain. Which of the following is the
most reliable indicator of a client's pain?
A) The client's vital signs.
B) The client's nonverbal cues.
C) The client's self-report of pain.
D) The nurse's observation of the client's behavior.
E) The client's previous pain medication history.
Correct Answer: C) The client's self-report of pain.
Rationale: Pain is a subjective experience, and the client's self-report
is always the most accurate and reliable indicator of their pain level,
as pain is "whatever the experiencing person says it is."
Question 3
A nurse is initiating a protective environment for a client who has a
,compromised immune system. Which of the following precautions should the
nurse implement?
A) Place the client in a private room with negative air pressure.
B) Ensure all staff wear an N95 respirator mask.
C) Restrict fresh flowers and potted plants in the client's room.
D) Wear a gown, mask, and gloves when entering the client's room.
E) Discard all disposable equipment after use.
Correct Answer: C) Restrict fresh flowers and potted plants in the
client's room.
Rationale: In a protective (reverse isolation) environment, fresh
flowers and plants can harbor mold and bacteria, posing a
significant risk of infection to a severely immunocompromised
client.
Question 4
A nurse is preparing to insert an indwelling urinary catheter for a female
client. Which of the following actions should the nurse take?
A) Position the client in a prone position.
B) Lubricate the catheter tip 1 to 2 inches.
C) Use non-sterile gloves to perform perineal care.
D) Inflate the balloon with 5 mL of sterile water before insertion.
E) Place the drainage bag on the client's abdomen.
Correct Answer: C) Use non-sterile gloves to perform perineal care.
Rationale: Perineal care prior to catheter insertion is a clean
procedure and can be performed with non-sterile gloves. The
catheter insertion itself requires sterile technique.
Question 5
A nurse is documenting in a client's medical record. Which of the following
documentation errors should the nurse recognize as a breach of
confidentiality?
A) Sharing client information verbally with another nurse involved in the
,client's care.
B) Leaving a client's medical record open on a computer screen where others
can view it.
C) Providing a copy of a client's lab results to the client's primary care
provider.
D) Discussing a client's condition with family members who have power of
attorney.
E) Reporting suspected child abuse to the appropriate authorities.
Correct Answer: B) Leaving a client's medical record open on a
computer screen where others can view it.
Rationale: Leaving protected health information (PHI) visible to
unauthorized individuals is a direct violation of HIPAA and
constitutes a breach of confidentiality, as it fails to protect patient
privacy.
Question 6
A nurse is caring for a client who is NPO and is scheduled for surgery. The
client suddenly vomits. Which of the following is the nurse's priority action?
A) Administer an antiemetic.
B) Provide oral hygiene.
C) Document the event.
D) Turn the client to their side.
E) Notify the surgeon.
Correct Answer: D) Turn the client to their side.
Rationale: Turning the client to their side is the priority intervention
to prevent aspiration, especially since they are NPO and therefore
at higher risk for complications if vomitus enters the lungs.
Question 7
A nurse is teaching a client about proper body mechanics. Which of the
following instructions should the nurse include?
A) Bend at the waist when lifting objects.
, B) Keep the feet close together for a broad base of support.
C) Use major muscle groups to lift objects.
D) Lift objects with straight knees.
E) Avoid tightening abdominal muscles when lifting.
Correct Answer: C) Use major muscle groups to lift objects.
Rationale: Using major muscle groups (legs, glutes, and core)
distributes the workload and prevents strain on smaller, weaker
muscles like those in the back, which is a key principle of good body
mechanics.
Question 8
A nurse is preparing to administer a subcutaneous injection. Which of the
following sites is appropriate for this injection?
A) Deltoid muscle.
B) Ventrogluteal muscle.
C) Outer posterior aspect of the upper arm.
D) Vastus lateralis muscle.
E) Dorsogluteal muscle.
Correct Answer: C) Outer posterior aspect of the upper arm.
Rationale: The outer posterior aspect of the upper arm, along with
the abdomen (at least 2 inches from the umbilicus) and anterior
thighs, are common and appropriate sites for subcutaneous
injections due to readily available adipose tissue.
Question 9
A nurse is caring for a client who is experiencing dyspnea. Which of the
following positions should the nurse place the client in?
A) Supine.
B) Prone.
C) Trendelenburg.
D) Fowler's.
E) Lithotomy.