EXAM QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES ||
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1.
A nurse is caring for a client who reports dizziness when standing. Which action
should the nurse take first?
A. Obtain orthostatic vital signs
B. Encourage increased fluid intake
C. Assist the client to ambulate
D. Apply compression stockings
Answer: A
Rationale: Orthostatic vital signs help determine if the client is experiencing
orthostatic hypotension, which is a priority assessment for dizziness upon standing.
2.
Which finding is an expected age-related change in an older adult?
A. Increased heart rate variability
B. Decreased skin elasticity
C. Increased lung compliance
D. Increased renal function
Answer: B
Rationale: Aging causes decreased collagen and elastin, leading to reduced skin
elasticity.
,3.
A nurse is preparing to administer oral medication. Which action is appropriate?
A. Crush all sustained-release tablets
B. Verify patient identity using room number
C. Check allergies before administration
D. Leave medications at bedside if the patient is asleep
Answer: C
Rationale: Verifying allergies is essential to prevent adverse reactions.
4.
A client has a prescription for oxygen at 2 L/min via nasal cannula. Which action
is appropriate?
A. Humidify oxygen if flow is above 4 L/min
B. Apply petroleum jelly to nares
C. Position prongs facing upward
D. Secure tubing tightly to ears
Answer: A
Rationale: Humidification is recommended for flows above 4 L/min to prevent
mucosal dryness.
5.
Which action demonstrates therapeutic communication?
A. “You shouldn’t feel that way.”
B. “Why did you miss your medication?”
C. “Tell me more about how you are feeling.”
D. “Everything will be fine soon.”
Answer: C
Rationale: Encouraging open-ended expression promotes therapeutic
communication.
,6.
A nurse is caring for a client with a suspected infection. Which precaution should
be implemented?
A. Standard precautions only
B. Contact precautions
C. Protective environment
D. No precautions needed
Answer: A
Rationale: Standard precautions are used for all clients, regardless of infection
status.
7.
Which vital sign requires immediate intervention?
A. Temperature 37.2°C (99°F)
B. Respiratory rate 28/min
C. Heart rate 88/min
D. Blood pressure 120/80 mmHg
Answer: B
Rationale: Tachypnea may indicate respiratory distress requiring prompt
evaluation.
8.
A nurse is evaluating pain in a postoperative client. Which scale is most
appropriate?
A. FLACC scale
B. APGAR score
C. Glasgow Coma Scale
D. Braden scale
Answer: A
Rationale: FLACC is used for patients unable to communicate pain verbally.
, 9.
Which action reduces risk of infection transmission?
A. Wearing gloves when entering room
B. Performing hand hygiene before and after patient contact
C. Using sterile gloves for all tasks
D. Wearing gown in all situations
Answer: B
Rationale: Hand hygiene is the most effective method to prevent infection spread.
10.
A client reports pain after surgery. Which intervention should the nurse implement
first?
A. Administer prescribed analgesic
B. Reposition the client
C. Notify provider
D. Apply ice pack
Answer: B
Rationale: Non-pharmacological interventions should be attempted first if
appropriate.
11.
Which client is at highest risk for pressure injury?
A. Ambulatory client
B. Client with diabetes and immobility
C. Client with good nutrition
D. Postoperative client walking daily
Answer: B
Rationale: Diabetes and immobility significantly increase risk due to poor
perfusion.