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1. A patient who is two days post-operative from an abdominal hysterectomy reports a sudden onset of
sharp chest pain and shortness of breath. What is the nurse's priority action?
A) Administer PRN pain medication and encourage deep breathing.
B) Place the patient in a high-Fowler's position and apply oxygen.
C) Assess the surgical incision for signs of infection or dehiscence.
D) Encourage the patient to ambulate to the bathroom to promote circulation.
Correct Answer: B) Place the patient in a high-Fowler's position and apply oxygen.
Rationale: This presentation is suspicious for a pulmonary embolism. The priority is to position the
patient for optimal ventilation and apply oxygen to stabilize respiratory status.
2. When preparing to administer an enteral feeding through a nasogastric tube, what is the most accurate
method for the nurse to verify the tube's placement before initiating the feeding?
A) Auscultate for a gurgling sound over the epigastric area after injecting air.
B) Measure the pH of the aspirated gastric fluid and compare to the expected range.
C) Observe the color and consistency of the fluid aspirated from the tube.
D) Ask the patient to speak or hum to confirm the tube is not in the trachea.
Correct Answer: B) Measure the pH of the aspirated gastric fluid and compare to the expected range.
Rationale: While not perfect, pH testing of aspirate (typically between 0-4) is considered more accurate
than auscultation for confirming gastric placement before each feeding.
3. A client with heart failure is prescribed furosemide. Which assessment finding indicates to the nurse
that the medication is having its desired therapeutic effect?
A) The client reports a decrease in the frequency of their cough.
B) The client's daily weight has decreased by two pounds in one week.
C) The client's serum potassium level has increased to 4.0 mEq/L.
D) The client's blood pressure has increased to 138/88 mmHg.
Correct Answer: B) The client's daily weight has decreased by two pounds in one week.
Rationale: Furosemide is a loop diuretic used to manage fluid overload. A consistent, gradual decrease in
daily weight is the most reliable indicator of effective diuresis and fluid loss.
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4. An older adult patient is admitted with dehydration and a serum sodium level of 152 mEq/L. Which
nursing intervention is the priority for this patient's plan of care?
A) Restrict all oral fluids to prevent further fluid overload.
B) Administer a hypotonic intravenous solution as prescribed.
C) Encourage the consumption of a high-sodium diet to correct the imbalance.
D) Place the patient on strict bed rest to prevent falls from weakness.
Correct Answer: B) Administer a hypotonic intravenous solution as prescribed.
Rationale: Hypernatremia indicates a water deficit. A hypotonic solution (like 0.45% NaCl) will help
dilute the serum sodium levels by shifting water into the intracellular space.
5. A nurse is caring for a patient who is NPO and has a nasogastric tube set to low intermittent suction.
The patient's serum potassium level is 3.2 mEq/L. Which assessment finding is most consistent with this
electrolyte imbalance?
A) The patient has hyperactive bowel sounds and diarrhea.
B) The patient reports muscle weakness and exhibits a flattened T-wave on the ECG.
C) The patient has a bounding pulse and jugular vein distention.
D) The patient's urine output has decreased to less than 30 mL/hr.
Correct Answer: B) The patient reports muscle weakness and exhibits a flattened T-wave on the ECG.
Rationale: Hypokalemia (K+ <3.5) often presents with muscle weakness and ECG changes such as
flattened or inverted T-waves and U-wave prominence.
6. While assessing a patient's surgical wound on the third day post-op, the nurse notes moderate
serosanguineous drainage and slight redness at the incision site. What is the most appropriate nursing
action based on these findings?
A) Irrigate the wound with a sterile normal saline solution.
B) Document the finding as a normal part of the healing process.
C) Apply a warm, moist compress to the area to promote circulation.
D) Obtain a wound culture to test for a potential infection.
Correct Answer: B) Document the finding as a normal part of the healing process.
Rationale: Serosanguineous drainage and slight erythema are expected inflammatory responses during
the initial stages of wound healing and are not necessarily indicative of infection.
7. A patient is prescribed 500 mg of a medication that is available in a liquid concentration of 250 mg/5
mL. How many milliliters will the nurse administer to the patient?
A) 2.5 mL
B) 5 mL
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C) 10 mL
D) 15 mL
Correct Answer: C) 10 mL
Rationale: Using the formula Desired/Dose on hand x Quantity = (500 mg / 250 mg) x 5 mL = 2 x 5 mL =
10 mL.
8. The nurse is providing discharge teaching to a patient who will be self-administering subcutaneous
heparin injections at home. Which statement made by the patient indicates a correct understanding of the
teaching?
A) "I will rub the injection site firmly after the injection to help the medicine absorb."
B) "I will rotate the injection sites between my abdomen and thighs to prevent bruising."
C) "I will aspirate for blood return before I push the plunger down to inject the medication."
D) "I will inject the heparin into the deltoid muscle to ensure rapid absorption."
Correct Answer: B) "I will rotate the injection sites between my abdomen and thighs to prevent bruising."
Rationale: Subcutaneous heparin should be given in the abdomen but can be rotated to the thighs. The
site should not be rubbed (to prevent hematoma), and aspiration is not recommended for subcutaneous
injections.
9. A patient with a history of chronic obstructive pulmonary disease is receiving oxygen at 2 L/min via
nasal cannula. Which assessment finding is most important for the nurse to monitor?
A) The patient's level of consciousness and respiratory rate.
B) The oxygen saturation level and the flow rate of the oxygen.
C) The condition of the patient's skin around the ears and nares.
D) The patient's ability to eat and drink without becoming short of breath.
Correct Answer: A) The patient's level of consciousness and respiratory rate.
Rationale: For a patient with COPD, the hypoxic drive may be a factor. The priority is to monitor for
decreased respiratory rate or altered LOC, which could indicate that the supplemental oxygen is
suppressing their drive to breathe.
10. A client reports severe, crushing chest pain that radiates down the left arm. The nurse administers
sublingual nitroglycerin as prescribed. What is the primary expected outcome for this patient after the
administration of this medication?
A) The patient's heart rate will decrease to within a normal range.
B) The patient's blood pressure will increase to baseline parameters.
C) The patient will report a significant reduction or cessation of chest pain.
D) The patient will experience a mild headache as a side effect of the drug.
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Correct Answer: C) The patient will report a significant reduction or cessation of chest pain.
Rationale: Nitroglycerin is a vasodilator used to relieve angina. Its primary therapeutic purpose is to
decrease myocardial oxygen demand and reduce chest pain.
11. The nurse is preparing to perform a sterile dressing change for a patient with a pressure injury. When
opening the sterile supplies, which action by the nurse would be a break in sterile technique?
A) Opening the outer flap of the sterile package away from the body.
B) Placing the sterile field on a clean, dry, flat work surface.
C) Discarding a sterile gauze pad that accidentally touches the edge of the sterile field.
D) Reaching across the sterile field to retrieve an additional item that is needed.
Correct Answer: D) Reaching across the sterile field to retrieve an additional item that is needed.
Rationale: Reaching over a sterile field contaminates the field by allowing non-sterile clothing or body
parts to shed microorganisms onto the sterile surface.
12. A patient has a new colostomy. Which statement by the patient indicates that the nurse's teaching
about stoma care has been effective?
A) "I will clean the stoma with soap and water to keep it free of drainage."
B) "I will massage the stoma if it looks pale and dusky to improve circulation."
C) "I will change the appliance system every day to prevent skin breakdown."
D) "I will cut the skin barrier one-quarter inch larger than the stoma size."
Correct Answer: A) "I will clean the stoma with soap and water to keep it free of drainage."
Rationale: The stoma itself can be cleaned with mild soap and water. A pale or dusky stoma indicates
poor perfusion and needs immediate reporting, not massage. The barrier should be cut to the exact size.
13. In planning care for a patient with a hip fracture who is in Buck's traction, which nursing intervention
is essential to maintain the proper alignment and function of the traction?
A) Ensure the weights are resting on the floor to provide counter-traction.
B) Keep the patient's heel elevated off the bed to prevent skin breakdown.
C) Adjust the ropes in the pulley system to allow for free movement of the joint.
D) Position the patient in a high-Fowler's position to improve lung expansion.
Correct Answer: B) Keep the patient's heel elevated off the bed to prevent skin breakdown.
Rationale: While maintaining traction, it is critical to prevent pressure injuries. The heel of the affected
leg should be off the bed to prevent skin breakdown and ensure proper alignment.
14. A patient is prescribed a beta-blocker, metoprolol, for the management of hypertension. Before
administering the medication, the nurse should hold the dose and contact the healthcare provider if the
1. A patient who is two days post-operative from an abdominal hysterectomy reports a sudden onset of
sharp chest pain and shortness of breath. What is the nurse's priority action?
A) Administer PRN pain medication and encourage deep breathing.
B) Place the patient in a high-Fowler's position and apply oxygen.
C) Assess the surgical incision for signs of infection or dehiscence.
D) Encourage the patient to ambulate to the bathroom to promote circulation.
Correct Answer: B) Place the patient in a high-Fowler's position and apply oxygen.
Rationale: This presentation is suspicious for a pulmonary embolism. The priority is to position the
patient for optimal ventilation and apply oxygen to stabilize respiratory status.
2. When preparing to administer an enteral feeding through a nasogastric tube, what is the most accurate
method for the nurse to verify the tube's placement before initiating the feeding?
A) Auscultate for a gurgling sound over the epigastric area after injecting air.
B) Measure the pH of the aspirated gastric fluid and compare to the expected range.
C) Observe the color and consistency of the fluid aspirated from the tube.
D) Ask the patient to speak or hum to confirm the tube is not in the trachea.
Correct Answer: B) Measure the pH of the aspirated gastric fluid and compare to the expected range.
Rationale: While not perfect, pH testing of aspirate (typically between 0-4) is considered more accurate
than auscultation for confirming gastric placement before each feeding.
3. A client with heart failure is prescribed furosemide. Which assessment finding indicates to the nurse
that the medication is having its desired therapeutic effect?
A) The client reports a decrease in the frequency of their cough.
B) The client's daily weight has decreased by two pounds in one week.
C) The client's serum potassium level has increased to 4.0 mEq/L.
D) The client's blood pressure has increased to 138/88 mmHg.
Correct Answer: B) The client's daily weight has decreased by two pounds in one week.
Rationale: Furosemide is a loop diuretic used to manage fluid overload. A consistent, gradual decrease in
daily weight is the most reliable indicator of effective diuresis and fluid loss.
,2|Page
4. An older adult patient is admitted with dehydration and a serum sodium level of 152 mEq/L. Which
nursing intervention is the priority for this patient's plan of care?
A) Restrict all oral fluids to prevent further fluid overload.
B) Administer a hypotonic intravenous solution as prescribed.
C) Encourage the consumption of a high-sodium diet to correct the imbalance.
D) Place the patient on strict bed rest to prevent falls from weakness.
Correct Answer: B) Administer a hypotonic intravenous solution as prescribed.
Rationale: Hypernatremia indicates a water deficit. A hypotonic solution (like 0.45% NaCl) will help
dilute the serum sodium levels by shifting water into the intracellular space.
5. A nurse is caring for a patient who is NPO and has a nasogastric tube set to low intermittent suction.
The patient's serum potassium level is 3.2 mEq/L. Which assessment finding is most consistent with this
electrolyte imbalance?
A) The patient has hyperactive bowel sounds and diarrhea.
B) The patient reports muscle weakness and exhibits a flattened T-wave on the ECG.
C) The patient has a bounding pulse and jugular vein distention.
D) The patient's urine output has decreased to less than 30 mL/hr.
Correct Answer: B) The patient reports muscle weakness and exhibits a flattened T-wave on the ECG.
Rationale: Hypokalemia (K+ <3.5) often presents with muscle weakness and ECG changes such as
flattened or inverted T-waves and U-wave prominence.
6. While assessing a patient's surgical wound on the third day post-op, the nurse notes moderate
serosanguineous drainage and slight redness at the incision site. What is the most appropriate nursing
action based on these findings?
A) Irrigate the wound with a sterile normal saline solution.
B) Document the finding as a normal part of the healing process.
C) Apply a warm, moist compress to the area to promote circulation.
D) Obtain a wound culture to test for a potential infection.
Correct Answer: B) Document the finding as a normal part of the healing process.
Rationale: Serosanguineous drainage and slight erythema are expected inflammatory responses during
the initial stages of wound healing and are not necessarily indicative of infection.
7. A patient is prescribed 500 mg of a medication that is available in a liquid concentration of 250 mg/5
mL. How many milliliters will the nurse administer to the patient?
A) 2.5 mL
B) 5 mL
,3|Page
C) 10 mL
D) 15 mL
Correct Answer: C) 10 mL
Rationale: Using the formula Desired/Dose on hand x Quantity = (500 mg / 250 mg) x 5 mL = 2 x 5 mL =
10 mL.
8. The nurse is providing discharge teaching to a patient who will be self-administering subcutaneous
heparin injections at home. Which statement made by the patient indicates a correct understanding of the
teaching?
A) "I will rub the injection site firmly after the injection to help the medicine absorb."
B) "I will rotate the injection sites between my abdomen and thighs to prevent bruising."
C) "I will aspirate for blood return before I push the plunger down to inject the medication."
D) "I will inject the heparin into the deltoid muscle to ensure rapid absorption."
Correct Answer: B) "I will rotate the injection sites between my abdomen and thighs to prevent bruising."
Rationale: Subcutaneous heparin should be given in the abdomen but can be rotated to the thighs. The
site should not be rubbed (to prevent hematoma), and aspiration is not recommended for subcutaneous
injections.
9. A patient with a history of chronic obstructive pulmonary disease is receiving oxygen at 2 L/min via
nasal cannula. Which assessment finding is most important for the nurse to monitor?
A) The patient's level of consciousness and respiratory rate.
B) The oxygen saturation level and the flow rate of the oxygen.
C) The condition of the patient's skin around the ears and nares.
D) The patient's ability to eat and drink without becoming short of breath.
Correct Answer: A) The patient's level of consciousness and respiratory rate.
Rationale: For a patient with COPD, the hypoxic drive may be a factor. The priority is to monitor for
decreased respiratory rate or altered LOC, which could indicate that the supplemental oxygen is
suppressing their drive to breathe.
10. A client reports severe, crushing chest pain that radiates down the left arm. The nurse administers
sublingual nitroglycerin as prescribed. What is the primary expected outcome for this patient after the
administration of this medication?
A) The patient's heart rate will decrease to within a normal range.
B) The patient's blood pressure will increase to baseline parameters.
C) The patient will report a significant reduction or cessation of chest pain.
D) The patient will experience a mild headache as a side effect of the drug.
, 4|Page
Correct Answer: C) The patient will report a significant reduction or cessation of chest pain.
Rationale: Nitroglycerin is a vasodilator used to relieve angina. Its primary therapeutic purpose is to
decrease myocardial oxygen demand and reduce chest pain.
11. The nurse is preparing to perform a sterile dressing change for a patient with a pressure injury. When
opening the sterile supplies, which action by the nurse would be a break in sterile technique?
A) Opening the outer flap of the sterile package away from the body.
B) Placing the sterile field on a clean, dry, flat work surface.
C) Discarding a sterile gauze pad that accidentally touches the edge of the sterile field.
D) Reaching across the sterile field to retrieve an additional item that is needed.
Correct Answer: D) Reaching across the sterile field to retrieve an additional item that is needed.
Rationale: Reaching over a sterile field contaminates the field by allowing non-sterile clothing or body
parts to shed microorganisms onto the sterile surface.
12. A patient has a new colostomy. Which statement by the patient indicates that the nurse's teaching
about stoma care has been effective?
A) "I will clean the stoma with soap and water to keep it free of drainage."
B) "I will massage the stoma if it looks pale and dusky to improve circulation."
C) "I will change the appliance system every day to prevent skin breakdown."
D) "I will cut the skin barrier one-quarter inch larger than the stoma size."
Correct Answer: A) "I will clean the stoma with soap and water to keep it free of drainage."
Rationale: The stoma itself can be cleaned with mild soap and water. A pale or dusky stoma indicates
poor perfusion and needs immediate reporting, not massage. The barrier should be cut to the exact size.
13. In planning care for a patient with a hip fracture who is in Buck's traction, which nursing intervention
is essential to maintain the proper alignment and function of the traction?
A) Ensure the weights are resting on the floor to provide counter-traction.
B) Keep the patient's heel elevated off the bed to prevent skin breakdown.
C) Adjust the ropes in the pulley system to allow for free movement of the joint.
D) Position the patient in a high-Fowler's position to improve lung expansion.
Correct Answer: B) Keep the patient's heel elevated off the bed to prevent skin breakdown.
Rationale: While maintaining traction, it is critical to prevent pressure injuries. The heel of the affected
leg should be off the bed to prevent skin breakdown and ensure proper alignment.
14. A patient is prescribed a beta-blocker, metoprolol, for the management of hypertension. Before
administering the medication, the nurse should hold the dose and contact the healthcare provider if the
