,Section 1: Fundamentals & Safety (Questions 1-30)
1. A nurse is preparing to administer a medication via a nasogastric (NG) tube.
Which of the following actions is most important for the nurse to take before
administering the medication?
A) Flush the tube with 30 mL of sterile water.
B) Verify the placement of the NG tube by aspirating gastric contents and
checking the pH.
C) Warm the medication to room temperature.
D) Place the patient in a supine position.
Correct Answer: B
Rationale: Verifying NG tube placement is the most critical safety step to
prevent accidental administration into the lungs. Aspiration of gastric
contents and pH testing (typically < 5) is a standard method. While flushing
and positioning are important, they come after placement is confirmed. A
supine position would increase the risk of aspiration.
2. A patient is on fall precautions. Which of the following interventions is most
appropriate for the nurse to implement?
A) Keep all four side rails up at all times.
B) Apply a vest restraint to prevent the patient from getting up.
C) Place the patient's call light within reach and instruct them on its use.
D) Keep the room completely dark to promote sleep.
,Correct Answer: C
Rationale: Placing the call light within reach empowers the patient to call for
assistance, which is a key, non-restrictive fall prevention strategy. Keeping all
four side rails up is a restraint and can be dangerous. Vest restraints require a
physician's order and should be a last resort. A dark room increases fall risk.
3. Which of the following is the most effective method for preventing the
spread of infection in a healthcare setting?
A) Wearing personal protective equipment (PPE) at all times.
B) Administering prophylactic antibiotics to all patients.
C) Performing hand hygiene before and after patient contact.
D) Isolating all patients with suspected infections.
Correct Answer: C
Rationale: Hand hygiene is the single most effective and fundamental method
to prevent the transmission of pathogens. While PPE, isolation, and antibiotics
are important, they are specific to certain situations, whereas hand hygiene is
a universal and primary defense.
4. A nurse is documenting a patient's pain using the PQRST mnemonic. What
does the "R" stand for?
A) Relief
B) Region
C) Radiation
D) Rating
Correct Answer: C
, Rationale: PQRST is a standard pain assessment tool: P
(Provocation/Palliation), Q (Quality), R (Radiation/Region), S
(Severity/Symptoms), T (Timing). 'Radiation' refers to where the pain travels.
5. The nurse is assessing a patient's capillary refill time. The nurse presses on
the patient's nail bed and it takes 4 seconds for the color to return. How
should the nurse interpret this finding?
A) Normal, indicating adequate perfusion.
B) Mildly delayed, but within acceptable limits.
C) Delayed, indicating possible peripheral hypoperfusion.
D) Inconclusive without further assessment.
Correct Answer: C
Rationale: Normal capillary refill time is less than 2 seconds. A refill time of 4
seconds is significantly delayed and suggests poor peripheral perfusion, which
could be due to conditions like shock, dehydration, or peripheral vascular
disease.
6. A patient is prescribed a clear liquid diet. Which of the following items is
allowed?
A) Orange juice with pulp
B) Cream of wheat
C) Chicken broth
D) Whole milk
Correct Answer: C
Rationale: A clear liquid diet consists of liquids that are transparent and leave
little residue in the GI tract. Chicken broth (strained), apple juice, gelatin, and
1. A nurse is preparing to administer a medication via a nasogastric (NG) tube.
Which of the following actions is most important for the nurse to take before
administering the medication?
A) Flush the tube with 30 mL of sterile water.
B) Verify the placement of the NG tube by aspirating gastric contents and
checking the pH.
C) Warm the medication to room temperature.
D) Place the patient in a supine position.
Correct Answer: B
Rationale: Verifying NG tube placement is the most critical safety step to
prevent accidental administration into the lungs. Aspiration of gastric
contents and pH testing (typically < 5) is a standard method. While flushing
and positioning are important, they come after placement is confirmed. A
supine position would increase the risk of aspiration.
2. A patient is on fall precautions. Which of the following interventions is most
appropriate for the nurse to implement?
A) Keep all four side rails up at all times.
B) Apply a vest restraint to prevent the patient from getting up.
C) Place the patient's call light within reach and instruct them on its use.
D) Keep the room completely dark to promote sleep.
,Correct Answer: C
Rationale: Placing the call light within reach empowers the patient to call for
assistance, which is a key, non-restrictive fall prevention strategy. Keeping all
four side rails up is a restraint and can be dangerous. Vest restraints require a
physician's order and should be a last resort. A dark room increases fall risk.
3. Which of the following is the most effective method for preventing the
spread of infection in a healthcare setting?
A) Wearing personal protective equipment (PPE) at all times.
B) Administering prophylactic antibiotics to all patients.
C) Performing hand hygiene before and after patient contact.
D) Isolating all patients with suspected infections.
Correct Answer: C
Rationale: Hand hygiene is the single most effective and fundamental method
to prevent the transmission of pathogens. While PPE, isolation, and antibiotics
are important, they are specific to certain situations, whereas hand hygiene is
a universal and primary defense.
4. A nurse is documenting a patient's pain using the PQRST mnemonic. What
does the "R" stand for?
A) Relief
B) Region
C) Radiation
D) Rating
Correct Answer: C
, Rationale: PQRST is a standard pain assessment tool: P
(Provocation/Palliation), Q (Quality), R (Radiation/Region), S
(Severity/Symptoms), T (Timing). 'Radiation' refers to where the pain travels.
5. The nurse is assessing a patient's capillary refill time. The nurse presses on
the patient's nail bed and it takes 4 seconds for the color to return. How
should the nurse interpret this finding?
A) Normal, indicating adequate perfusion.
B) Mildly delayed, but within acceptable limits.
C) Delayed, indicating possible peripheral hypoperfusion.
D) Inconclusive without further assessment.
Correct Answer: C
Rationale: Normal capillary refill time is less than 2 seconds. A refill time of 4
seconds is significantly delayed and suggests poor peripheral perfusion, which
could be due to conditions like shock, dehydration, or peripheral vascular
disease.
6. A patient is prescribed a clear liquid diet. Which of the following items is
allowed?
A) Orange juice with pulp
B) Cream of wheat
C) Chicken broth
D) Whole milk
Correct Answer: C
Rationale: A clear liquid diet consists of liquids that are transparent and leave
little residue in the GI tract. Chicken broth (strained), apple juice, gelatin, and
