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Section 1: Fundamentals of Nursing
Question 1
A nurse is caring for a client who is postoperative day 1 following abdominal surgery.
The client reports pain at the incision site rated 6/10. Which action should the nurse
take first?
A. Administer the prescribed analgesic.
B. Assess the incision for signs of dehiscence.
C. Reposition the client to promote comfort.
D. Teach the client about nonpharmacological pain relief measures.
Correct Answer: A. Administer the prescribed analgesic.
Rationale: The nurse's priority is to address the client's pain using the prescribed
analgesic. While repositioning (C) and nonpharmacological measures (D) are
appropriate adjuncts, they are not the first action for moderate postoperative pain.
Assessing for dehiscence (B) is important but not indicated unless there are signs of
wound complications; pain alone does not warrant this as the first action.
Question 2
A nurse is preparing to administer a subcutaneous injection of heparin to a client. Which
action by the nurse demonstrates correct technique?
A. Aspirating before injecting the medication.
B. Injecting the medication into the muscle tissue.
,C. Administering the injection at a 45- to 90-degree angle.
D. Massaging the site after injection to promote absorption.
Correct Answer: C. Administering the injection at a 45- to 90-degree angle.
Rationale: Subcutaneous injections are administered at a 45- to 90-degree angle
depending on the client's body habitus. Aspirating (A) is not recommended for
subcutaneous heparin due to the risk of hematoma. Injecting into muscle (B) is
incorrect for subcutaneous administration. Massaging (D) is contraindicated after
heparin injection as it can cause bruising and bleeding.
Question 3
A nurse is caring for a client with a prescription for contact precautions. Which piece of
personal protective equipment (PPE) is required when entering the client's room?
A. N95 respirator
B. Gown and gloves
C. Goggles and face shield
D. Powered air-purifying respirator (PAPR)
Correct Answer: B. Gown and gloves
Rationale: Contact precautions require a gown and gloves upon entry to the room. An
N95 respirator (A) is used for airborne precautions. Goggles and face shield (C) are
used for droplet or splash precautions. A PAPR (D) is used for high-risk airborne
precautions. Contact precautions are implemented for infections transmitted by direct
or indirect contact.
Question 4
A nurse is assessing a client who is receiving oxygen at 4 L/min via nasal cannula.
Which finding indicates the therapy is effective?
A. Oxygen saturation of 96%
B. Respiratory rate of 28 breaths/min
,C. Client reports mild dyspnea
D. Use of accessory muscles during breathing
Correct Answer: A. Oxygen saturation of 96%
Rationale: An oxygen saturation of 96% indicates effective oxygenation. A respiratory
rate of 28 (B) is tachypneic and indicates respiratory distress. Mild dyspnea (C) and use
of accessory muscles (D) are signs of inadequate oxygenation and require further
intervention.
Question 5
A nurse is providing discharge teaching to a client about preventing falls at home.
Which statement by the client indicates understanding of the teaching?
A. "I will keep a night-light on in the bathroom."
B. "I should wear socks without shoes when walking at home."
C. "I will place my medications on the highest shelf in the cabinet."
D. "I should avoid using handrails when going up stairs."
Correct Answer: A. "I will keep a night-light on in the bathroom."
Rationale: Keeping a night-light on reduces fall risk by improving visibility. Wearing
socks without shoes (B) increases slip risk. Placing medications on the highest shelf
(C) increases fall risk from reaching. Avoiding handrails (D) removes a safety support
and increases fall risk.
Question 6
A nurse is caring for a client who is on bed rest. Which action should the nurse take to
prevent the development of a pressure injury?
A. Reposition the client every 4 hours.
B. Massage bony prominences every 2 hours.
C. Keep the head of the bed elevated to 45 degrees continuously.
D. Use a pressure-redistribution mattress overlay.
, Correct Answer: D. Use a pressure-redistribution mattress overlay.
Rationale: A pressure-redistribution mattress overlay is an evidence-based intervention
to reduce pressure injury risk. Clients should be repositioned every 2 hours (not 4, A).
Massaging bony prominences (B) is contraindicated as it can cause deep tissue
damage. Keeping the head of the bed at 45 degrees continuously (C) increases sacral
shear and pressure injury risk.
Question 7
A nurse is preparing to transfer a client from the bed to a wheelchair using a pivot
transfer. Which action should the nurse take first?
A. Lock the wheels on the bed and wheelchair.
B. Assist the client to a sitting position on the edge of the bed.
C. Place the client's feet flat on the floor.
D. Instruct the client to place their hands on the nurse's shoulders.
Correct Answer: A. Lock the wheels on the bed and wheelchair.
Rationale: Safety is the priority. The nurse must lock the wheels on both the bed and
wheelchair before initiating any transfer to prevent movement and potential injury. The
other actions follow after ensuring equipment stability.
Question 8
A nurse is caring for a client who has a prescription for a 24-hour urine collection. Which
instruction should the nurse provide to the client?
A. "Discard the first voided urine and begin collecting all urine after that."
B. "Collect all urine for 24 hours, including the first voided urine of the collection period."
C. "Keep the urine specimen at room temperature during the collection period."
D. "Void directly into the collection container without using a toilet hat."
Correct Answer: A. "Discard the first voided urine and begin collecting all urine after
that."