Style) 200 Questions & Answers | 2 versions
Latest 2026 Practice Test with Rationales | Instant
Pdf Download
Case Scenario (Questions 1–3)
A nurse is caring for a 68-year-old client admitted with pneumonia who has a productive
cough, fever, and oxygen saturation of 90% on room air.
1. Which assessment finding requires immediate nursing intervention for this client
with pneumonia?
A. Productive cough with yellow sputum
B. Temperature of 38.2°C (100.8°F)
C. Oxygen saturation of 90% on room air
D. Mild fatigue
Rationale: Low oxygen saturation indicates impaired oxygenation and requires urgent
action.
2. Which nursing intervention is priority to improve oxygenation for this client?
A. Encourage oral fluids
B. Administer antibiotics
C. Position client in high Fowler’s position
D. Provide teaching
Rationale: High Fowler’s maximizes lung expansion.
3. (SATA) Which interventions should the nurse implement for this client? (Select all
that apply)
,A. Encourage coughing and deep breathing exercises
B. Restrict fluids
C. Administer prescribed oxygen therapy
D. Keep client flat
E. Monitor oxygen saturation regularly
Rationale: Airway clearance and oxygen support are essential.
4. A nurse is performing hand hygiene; which action is most appropriate according to
infection control guidelines?
A. Use hot water
B. Skip drying
C. Rub hands for at least 20 seconds
D. Use gloves instead
Rationale: Proper duration ensures pathogen removal.
5. Which isolation precaution is required for a client diagnosed with tuberculosis?
A. Contact
B. Droplet
C. Airborne
D. Standard only
Rationale: TB spreads via airborne particles.
6. A nurse is caring for a postoperative client; which finding indicates a possible
infection?
A. Clear drainage
B. Pain level 3
C. Redness and warmth at incision site
D. Normal temperature
Rationale: Redness and warmth indicate inflammation/infection.
,7. Which action demonstrates proper body mechanics when lifting a heavy object?
A. Bend at waist
B. Twist spine
C. Keep object close and bend knees
D. Lift quickly
Rationale: Prevents injury.
8. A nurse is assessing pain using a numeric scale; what is the purpose of this
assessment?
A. Diagnose disease
B. Quantify client’s subjective pain level
C. Measure temperature
D. Replace treatment
Rationale: Pain is subjective.
9. Which client is at highest risk for falls in a hospital setting?
A. Young adult
B. Athlete
C. Older adult with mobility issues
D. Healthy teen
Rationale: Age + mobility = high risk.
10. (SATA) Which measures help prevent pressure ulcers in immobile clients?
A. Reposition every 2 hours
B. Use firm mattress
C. Keep skin clean and dry
D. Massage bony areas
E. Use pressure-relieving devices
Rationale: Prevention focuses on circulation and skin care.
, 11. A nurse is preparing to administer medication; which is part of the “five rights”?
A. Right diagnosis
B. Right insurance
C. Right patient
D. Right room
Rationale: Ensures safe medication administration.
12. Which route of medication administration provides the fastest systemic effect?
A. Oral
B. Subcutaneous
C. Intramuscular
D. Intravenous
Rationale: Direct bloodstream delivery.
13. A nurse is caring for a dehydrated client; which sign supports this diagnosis?
A. Moist mucous membranes
B. Dry skin and decreased urine output
C. Weight gain
D. Clear urine
Rationale: Classic dehydration signs.
14. Which electrolyte imbalance is most associated with cardiac dysrhythmias?
A. Sodium
B. Calcium
C. Potassium imbalance
D. Chloride
Rationale: Potassium affects cardiac conduction.
15. A nurse is teaching a client about incentive spirometry; what is the purpose?