Fundamentals of
Nursing, Health
Assessment, and
Patient Safety 20226
**Target Question Count: 80**
---
### Question 1
The nurse is performing a focused respiratory assessment on a patient with a history of asthma. Which
finding requires immediate intervention?
A. Wheezing heard on expiration
B. Respiratory rate of 22 breaths per minute
,C. Use of accessory muscles during inspiration
D. Oxygen saturation of 94% on room air
💫RATIONALE✔️✔️: Use of accessory muscles during inspiration indicates respiratory distress and
impending respiratory failure. This requires immediate intervention, including assessment of airway
patency, administration of bronchodilators, and possible oxygen therapy.
💫ANSWER✔️✔️: C. Use of accessory muscles during inspiration
---
### Question 2
A patient who is 2 days post-operative from abdominal surgery reports feeling "something give way" in
the incision site. The nurse observes a small amount of serosanguineous drainage on the dressing.
Which action should the nurse take first?
A. Apply an abdominal binder
B. Assess the wound for dehiscence
C. Notify the healthcare provider
D. Place the patient in a supine position
💫RATIONALE✔️✔️: The sensation of "something giving way" in the incision site with
serosanguineous drainage is a classic sign of wound dehiscence. The nurse should immediately assess
the wound by inspecting it with a sterile gloved hand to determine if dehiscence or evisceration has
occurred.
💫ANSWER✔️✔️: B. Assess the wound for dehiscence
,---
### Question 3
The nurse is preparing to administer an intramuscular injection in the ventrogluteal site. Which action is
essential for proper site identification?
A. Place the patient in a prone position with the toes pointing inward
B. Locate the greater trochanter and the anterior superior iliac spine
C. Use the palm of the hand to locate the injection site
D. Identify the midpoint of the vastus lateralis muscle
💫RATIONALE✔️✔️: To locate the ventrogluteal site, the nurse identifies the greater trochanter and
the anterior superior iliac spine. The injection site is in the center of the triangle formed by these
landmarks.
💫ANSWER✔️✔️: B. Locate the greater trochanter and the anterior superior iliac spine
---
### Question 4
A patient with a history of falls is being discharged to home. Which instruction should the nurse include
in the discharge teaching to promote safety?
A. "Use throw rugs to prevent slipping on hardwood floors."
, B. "Keep pathways clear of clutter and secure electrical cords."
C. "Install dim lighting to reduce glare."
D. "Wear socks without grips for comfort."
💫RATIONALE✔️✔️: Keeping pathways clear of clutter and securing electrical cords reduces the risk
of falls. Other safety measures include adequate lighting, removal of throw rugs, and wearing non-skid
footwear.
💫ANSWER✔️✔️: B. "Keep pathways clear of clutter and secure electrical cords."
---
### Question 5
The nurse is assessing a patient's peripheral vascular status. Which technique should the nurse use to
assess capillary refill?
A. Palpate the radial pulse for 30 seconds
B. Apply pressure to the nail bed until it blanches
C. Inspect the skin for color and temperature
D. Measure the circumference of the extremities
💫RATIONALE✔️✔️: Capillary refill is assessed by applying pressure to the nail bed until it blanches,
then releasing the pressure and noting the time for color to return. Normal capillary refill is less than 2
seconds.
💫ANSWER✔️✔️: B. Apply pressure to the nail bed until it blanches
Nursing, Health
Assessment, and
Patient Safety 20226
**Target Question Count: 80**
---
### Question 1
The nurse is performing a focused respiratory assessment on a patient with a history of asthma. Which
finding requires immediate intervention?
A. Wheezing heard on expiration
B. Respiratory rate of 22 breaths per minute
,C. Use of accessory muscles during inspiration
D. Oxygen saturation of 94% on room air
💫RATIONALE✔️✔️: Use of accessory muscles during inspiration indicates respiratory distress and
impending respiratory failure. This requires immediate intervention, including assessment of airway
patency, administration of bronchodilators, and possible oxygen therapy.
💫ANSWER✔️✔️: C. Use of accessory muscles during inspiration
---
### Question 2
A patient who is 2 days post-operative from abdominal surgery reports feeling "something give way" in
the incision site. The nurse observes a small amount of serosanguineous drainage on the dressing.
Which action should the nurse take first?
A. Apply an abdominal binder
B. Assess the wound for dehiscence
C. Notify the healthcare provider
D. Place the patient in a supine position
💫RATIONALE✔️✔️: The sensation of "something giving way" in the incision site with
serosanguineous drainage is a classic sign of wound dehiscence. The nurse should immediately assess
the wound by inspecting it with a sterile gloved hand to determine if dehiscence or evisceration has
occurred.
💫ANSWER✔️✔️: B. Assess the wound for dehiscence
,---
### Question 3
The nurse is preparing to administer an intramuscular injection in the ventrogluteal site. Which action is
essential for proper site identification?
A. Place the patient in a prone position with the toes pointing inward
B. Locate the greater trochanter and the anterior superior iliac spine
C. Use the palm of the hand to locate the injection site
D. Identify the midpoint of the vastus lateralis muscle
💫RATIONALE✔️✔️: To locate the ventrogluteal site, the nurse identifies the greater trochanter and
the anterior superior iliac spine. The injection site is in the center of the triangle formed by these
landmarks.
💫ANSWER✔️✔️: B. Locate the greater trochanter and the anterior superior iliac spine
---
### Question 4
A patient with a history of falls is being discharged to home. Which instruction should the nurse include
in the discharge teaching to promote safety?
A. "Use throw rugs to prevent slipping on hardwood floors."
, B. "Keep pathways clear of clutter and secure electrical cords."
C. "Install dim lighting to reduce glare."
D. "Wear socks without grips for comfort."
💫RATIONALE✔️✔️: Keeping pathways clear of clutter and securing electrical cords reduces the risk
of falls. Other safety measures include adequate lighting, removal of throw rugs, and wearing non-skid
footwear.
💫ANSWER✔️✔️: B. "Keep pathways clear of clutter and secure electrical cords."
---
### Question 5
The nurse is assessing a patient's peripheral vascular status. Which technique should the nurse use to
assess capillary refill?
A. Palpate the radial pulse for 30 seconds
B. Apply pressure to the nail bed until it blanches
C. Inspect the skin for color and temperature
D. Measure the circumference of the extremities
💫RATIONALE✔️✔️: Capillary refill is assessed by applying pressure to the nail bed until it blanches,
then releasing the pressure and noting the time for color to return. Normal capillary refill is less than 2
seconds.
💫ANSWER✔️✔️: B. Apply pressure to the nail bed until it blanches
