REAL EXAM QUESTIONS & VERIFIED ANSWERS - PASS
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EXAM
Question 1
A nurse is collaborating with a risk management team about potential legal issues involving
client care. The nurse should identify which of the following situations is an example of
negligence?
A. A nurse administers a medication without first identifying the client.
B. An assistive personnel discusses client care in the facility cafeteria with visitors present.
C. A nurse begins a blood transfusion without obtaining consent.
D. An assistive personnel prevents a client from leaving the facility.
Correct Answer: A
Rationale: Negligence is defined as a failure to take proper care or follow established standards
of practice, resulting in potential or actual harm to a patient. Administering a medication
without verifying the client's identity violates the basic standard of care (the rights of medication
administration).
(Note: Initiating a treatment or blood transfusion without obtaining informed consent is legally
classified as battery, which is an intentional tort, rather than negligence. Discussing private
patient info is a HIPAA breach, and preventing a patient from leaving is false imprisonment).
Question 2
A nurse is preparing to obtain informed consent from a client who speaks a different language.
Which of the following actions should the nurse take?
A. Request that an assistive personnel interpret the information for the client.
B. Use proper medical terms when giving information to the client.
C. Offer written information in the client's language.
D. Avoid using gestures when speaking to the client.
,Correct Answer: C
Rationale: Providing written educational and consent materials in the client’s native language
ensures comprehensive understanding and supports autonomous decision-making. To comply
with legal and professional standards, only a certified medical interpreter should translate
spoken clinical information; using untrained assistive personnel or family members is
inappropriate.
Question 3
A nurse is planning care for a client who reports insomnia. Which action should the nurse
perform shortly before bedtime?
A. Provide a late supper.
B. Offer a wet washcloth for the client to wash her face.
C. Perform range-of-motion exercises.
D. Prepare hot cocoa or tea for the client.
Correct Answer: A
Rationale: A light snack or small meal shortly before bed can promote sleep by preventing
hunger pangs and providing carbohydrates or tryptophan, which aid in relaxation. Traditional hot
cocoa or teas often contain caffeine, which acts as a stimulant and worsens insomnia, while
rigorous range-of-motion exercises are overly stimulating close to bedtime.
Question 4
A nurse is preparing to insert a peripheral IV catheter. Which of the following actions should the
nurse take to help dilate the vein?
A. Stroke the skin near the vein in an upward position.
B. Dangle the client's arm over the edge of the bed.
C. Apply a cool compress to the vein for 10 minutes.
D. Instruct the client to flex their arm with the hand open.
Correct Answer: B
Rationale: Dangling the patient's extremity below the level of the heart uses gravity to increase
venous congestion and hydrostatic pressure, which naturally distends and dilates peripheral
veins for easier cannulation. Cool compresses cause vasoconstriction and should be avoided,
whereas warm compresses promote dilation.
, Question 5
A nurse is preparing to suction a client’s tracheostomy tube. What action should the nurse take?
A. Apply intermittent suction during catheter insertion.
B. Suction the airway for 20 seconds with each pass.
C. Hyperoxygenate the client for 30 to 60 seconds after suctioning.
D. Decrease suction pressure to 150 mm Hg if O₂ saturation drops.
Correct Answer: C
Rationale: To prevent profound hypoxia, the nurse must hyperoxygenate the client with 100%
oxygen before and immediately after suctioning passes. Suction must never be applied during
insertion as it causes mucosal trauma; instead, it is applied intermittently only while
withdrawing the catheter. Individual suction passes must be limited to 10–15 seconds maximum.
Question 6
A nurse enters the room of a client who has a seizure disorder. The client, sitting in a chair,
begins to have a tonic-clonic seizure. What should the nurse do first?
A. Move items in the room away from the client.
B. Turn the client onto their side.
C. Help the client lie on the floor.
D. Loosen the client’s clothing.
Correct Answer: C
Rationale: The immediate priority safety action is to prevent injury from falling out of the chair.
Helping the client safely down to the floor provides a stable surface. Once on the floor, the nurse
should clear nearby sharp objects, turn the client into a side-lying position to protect the airway,
and loosen restrictive clothing.
Question 7
A nurse is testing for conduction deafness using Weber's test. What should the nurse do?
A. Move a vibrating tuning fork in front of each ear canal.
B. Place the base of the tuning fork on the client’s mastoid process.
C. Place the base of a vibrating tuning fork on the top of the client’s head.