COMPLETE EXAM-STYLE QUESTIONS |
ANSWERS & DETAILED RATIONALES LATEST UPDATE
2026/2027
SECTION 1: MANAGEMENT OF CARE & PRIORITIZATION (Questions 1-30)
Question 1:
A nurse in an emergency department is assessing four clients. Which client should
the nurse assess first?
A) A client with COPD who has a respiratory rate of 28/min
B) A client with chest pain who reports a rating of 7 on a 0-10 pain scale
C) A client with a temperature of 39°C (102.2°F) and confusion [CORRECT]
D) A client with a laceration who is bleeding through a dressing
Rationale: The client with fever and confusion is at risk for sepsis and
neurological compromise. Confusion indicates a change in mental status, which is
a priority finding. ABCs (airway, breathing, circulation) are always the first
priority, but systemic infection with neurological symptoms takes precedence
over
chronic conditions or stable wounds.
Question 2:
A charge nurse is assigning clients to nursing staff. Which client should be
assigned to the most experienced nurse?
A) A client who requires a wound irrigation
B) A client who is 1 day postoperative following a hip replacement
C) A client who is receiving IV antibiotics for pneumonia
D) A client who is exhibiting signs of a stroke [CORRECT]
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,Rationale: A client with stroke symptoms is unstable and requires rapid
assessment
and intervention. This client should be assigned to the most experienced nurse
who can recognize subtle neurological changes and act quickly.
Question 3:
A nurse is preparing to discharge a client who speaks a different language.
The nurse should use which method to provide discharge instructions?
A) Ask a family member to translate
B) Use a translator phone service
C) Provide written instructions in the client's language
D) Use a certified medical interpreter [CORRECT]
Rationale: Certified medical interpreters are the gold standard for patient
education. Family members are not reliable due to potential bias or lack of
medical knowledge. Written instructions alone are insufficient, and phone
interpreters are acceptable but not ideal for complex discharge teaching.
Question 4:
A nurse is caring for a client who has a living will. The client becomes
unresponsive and requires emergency surgery. What should the nurse do?
A) Follow the living will directives
B) Contact the client's next of kin for consent
C) Proceed with surgery as a life-saving measure [CORRECT]
D) Contact the hospital ethics committee
Rationale: A living will provides guidance for end-of-life decisions. In an
emergency, the nurse should follow the client's advance directives. However, if
the situation is life-threatening and time is critical, the standard of care is
to proceed with life-saving interventions unless a DNR/DNI is clearly documented.
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,The nurse should attempt to contact the healthcare proxy if time permits.
Question 5:
A nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task
is appropriate to delegate?
A) Assessing a client's wound drainage
B) Administering oral medications
C) Measuring intake and output [CORRECT]
D) Teaching a client about insulin administration
Rationale: Measuring intake and output is a routine task that can be delegated to
UAP. Assessment, medication administration, and teaching are beyond the scope
of
UAP and require licensed nursing judgment.
Question 6:
A nurse is triaging clients after a mass casualty event. Which client should be
given the highest priority (RED tag)?
A) A client with a minor laceration and stable vitals
B) A client with respiratory distress and a patent airway [CORRECT]
C) A client with a traumatic amputation and severe bleeding
D) A client who is unresponsive with no pulse
Rationale: In triage, RED tag clients have life-threatening conditions that are
treatable with immediate intervention. Respiratory distress is a priority.
Unresponsive with no pulse is BLACK (expectant) in mass casualty. Amputation
with
bleeding is RED but respiratory distress is the more immediate threat.
Question 7:
A nurse is providing teaching about advance directives to a newly admitted client.
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, Which statement by the client indicates understanding?
A) "I can only make changes to my advance directive once per year."
B) "My advance directive is only valid while I am in the hospital."
C) "I can designate a healthcare proxy to make decisions for me." [CORRECT]
D) "My family cannot override my advance directive."
Rationale: A healthcare proxy (durable power of attorney for healthcare) is a key
component of advance directives. Clients can change directives at any time, they
apply across settings, and family can challenge but not simply override.
Question 8:
A nurse is planning care for a client who has a new diagnosis of diabetes. Which
interdisciplinary team member should the nurse consult first?
A) Physical therapist
B) Registered dietitian [CORRECT]
C) Social worker
D) Occupational therapist
Rationale: Diet is fundamental to diabetes management. The dietitian should be
consulted early for meal planning and carbohydrate counting education.
Question 9:
A nurse is preparing to administer a blood transfusion to a client. What is the
nurse's priority action before starting the transfusion?
A) Premedicate with antihistamines
B) Assess baseline vital signs
C) Verify the blood product with another licensed nurse [CORRECT]
D) Start a second IV line
Rationale: Verification of the blood product (two-nurse check of blood type,
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