COMPREHENSIVE NURSING EXAM
QUESTIONS (1-350) QUESTIONS AND
CORRECT ANSWERS WITH DETAILED
RATIONALES
Category 1: Fundamentals of Nursing & Safety (Questions 1-50)
1. A nurse is preparing to insert an indwelling urinary catheter for a female
patient. Which of the following actions is most appropriate to maintain
sterility?
A. Use a sterile lubricant from a multi-dose tube for the catheter tip.
B. Clean the meatus with antiseptic solution using a circular motion from the
outside in.
C. Hold the labia apart with your non-dominant hand throughout the
procedure.
D. Advance the catheter 1-2 inches into the urethra until urine flows.
Correct Answer: C
Rationale: The non-dominant hand is considered contaminated once it
touches the patient's perineum. It must remain in that position to keep the
labia separated, while the dominant hand performs the sterile procedure.
Option A is incorrect because a sterile, single-use lubricant packet should be
used. Option B is incorrect because the cleansing motion should be from the
inside out (meatus outward). Option D is incorrect; for a female, advance the
catheter 2-3 inches.
,2. A patient is on fall precautions. Which of the following interventions is the
priority?
A. Placing the bed in the lowest position.
B. Keeping the call light within reach.
C. Ensuring the bedside table is within reach.
D. Assisting the patient with ambulation.
Correct Answer: A
Rationale: While all options are important, placing the bed in the lowest
position is the most critical intervention to minimize injury if a fall occurs. It's
a foundational safety measure.
3. The nurse is assessing a patient's peripheral IV site. Which finding indicates
early phlebitis?
A. Pallor and coolness of the skin around the site.
B. Edema and a slow infusion rate.
C. Erythema and localized pain along the vein.
D. Puffiness and a feeling of tightness around the site.
Correct Answer: C
Rationale: Erythema (redness) and localized pain are classic early signs of
phlebitis (inflammation of the vein). Pallor and coolness are signs of
infiltration or arterial insufficiency. Edema and a slow rate can indicate
infiltration.
4. According to the principles of medical asepsis, which of the following is a
key difference between medical and surgical asepsis?
A. Medical asepsis eliminates all microorganisms.
B. Surgical asepsis is used for wound care.
,C. Medical asepsis reduces the number of pathogens.
D. Surgical asepsis is not necessary for invasive procedures.
Correct Answer: C
Rationale: Medical asepsis (clean technique) aims to reduce the number and
transmission of pathogens. Surgical asepsis (sterile technique) aims to
eliminate all microorganisms from an area.
5. A patient with a nasogastric (NG) tube to suction has a gastric residual
volume (GRV) of 250 mL 4 hours after a continuous feeding. What is the
nurse's priority action?
A. Reinstill the aspirate and increase the feeding rate.
B. Discard the aspirate and hold the feeding for 8 hours.
C. Reinstill the aspirate and notify the healthcare provider.
D. Discard the aspirate and continue the feeding as ordered.
Correct Answer: C
Rationale: A GRV of 250 mL or greater is generally considered high
(depending on facility policy). The aspirate should be reinstilled to prevent
electrolyte loss, but the healthcare provider should be notified to adjust the
feeding plan. Holding the feeding without an order is not appropriate.
6. Which of the following is the most reliable indicator of a patient's pain?
A. The patient's vital signs.
B. The patient's self-report of pain.
C. The nurse's observation of the patient's behavior.
D. The results of an MRI or CT scan.
Correct Answer: B
, Rationale: Pain is subjective. The patient's own verbal report is the single
most reliable indicator of pain. While vital signs and behavior can provide
clues, they are not always accurate.
7. The nurse is providing oral care to an unconscious patient. Which position
is safest for this procedure?
A. Supine with a small pillow under the head.
B. Fowler's position.
C. Side-lying position.
D. Trendelenburg position.
Correct Answer: C
Rationale: The side-lying position allows drainage of fluids and secretions
from the mouth, preventing aspiration.
8. A patient is prescribed a liquid medication. What is the most accurate way
to measure the dose?
A. Use a standard household teaspoon.
B. Use a calibrated medicine cup.
C. Pour the liquid directly into the patient's mouth from the bottle.
D. Use a disposable plastic cup.
Correct Answer: B
Rationale: A calibrated medicine cup or an oral syringe is the most accurate
way to measure liquid medications. Household utensils vary significantly in
size. The dose should not be "eyeballed."
9. The nurse is preparing to apply a warm compress to a patient's inflamed
joint. Which of the following is the most appropriate action?
A. Apply the compress for 45 minutes to ensure therapeutic effect.
QUESTIONS (1-350) QUESTIONS AND
CORRECT ANSWERS WITH DETAILED
RATIONALES
Category 1: Fundamentals of Nursing & Safety (Questions 1-50)
1. A nurse is preparing to insert an indwelling urinary catheter for a female
patient. Which of the following actions is most appropriate to maintain
sterility?
A. Use a sterile lubricant from a multi-dose tube for the catheter tip.
B. Clean the meatus with antiseptic solution using a circular motion from the
outside in.
C. Hold the labia apart with your non-dominant hand throughout the
procedure.
D. Advance the catheter 1-2 inches into the urethra until urine flows.
Correct Answer: C
Rationale: The non-dominant hand is considered contaminated once it
touches the patient's perineum. It must remain in that position to keep the
labia separated, while the dominant hand performs the sterile procedure.
Option A is incorrect because a sterile, single-use lubricant packet should be
used. Option B is incorrect because the cleansing motion should be from the
inside out (meatus outward). Option D is incorrect; for a female, advance the
catheter 2-3 inches.
,2. A patient is on fall precautions. Which of the following interventions is the
priority?
A. Placing the bed in the lowest position.
B. Keeping the call light within reach.
C. Ensuring the bedside table is within reach.
D. Assisting the patient with ambulation.
Correct Answer: A
Rationale: While all options are important, placing the bed in the lowest
position is the most critical intervention to minimize injury if a fall occurs. It's
a foundational safety measure.
3. The nurse is assessing a patient's peripheral IV site. Which finding indicates
early phlebitis?
A. Pallor and coolness of the skin around the site.
B. Edema and a slow infusion rate.
C. Erythema and localized pain along the vein.
D. Puffiness and a feeling of tightness around the site.
Correct Answer: C
Rationale: Erythema (redness) and localized pain are classic early signs of
phlebitis (inflammation of the vein). Pallor and coolness are signs of
infiltration or arterial insufficiency. Edema and a slow rate can indicate
infiltration.
4. According to the principles of medical asepsis, which of the following is a
key difference between medical and surgical asepsis?
A. Medical asepsis eliminates all microorganisms.
B. Surgical asepsis is used for wound care.
,C. Medical asepsis reduces the number of pathogens.
D. Surgical asepsis is not necessary for invasive procedures.
Correct Answer: C
Rationale: Medical asepsis (clean technique) aims to reduce the number and
transmission of pathogens. Surgical asepsis (sterile technique) aims to
eliminate all microorganisms from an area.
5. A patient with a nasogastric (NG) tube to suction has a gastric residual
volume (GRV) of 250 mL 4 hours after a continuous feeding. What is the
nurse's priority action?
A. Reinstill the aspirate and increase the feeding rate.
B. Discard the aspirate and hold the feeding for 8 hours.
C. Reinstill the aspirate and notify the healthcare provider.
D. Discard the aspirate and continue the feeding as ordered.
Correct Answer: C
Rationale: A GRV of 250 mL or greater is generally considered high
(depending on facility policy). The aspirate should be reinstilled to prevent
electrolyte loss, but the healthcare provider should be notified to adjust the
feeding plan. Holding the feeding without an order is not appropriate.
6. Which of the following is the most reliable indicator of a patient's pain?
A. The patient's vital signs.
B. The patient's self-report of pain.
C. The nurse's observation of the patient's behavior.
D. The results of an MRI or CT scan.
Correct Answer: B
, Rationale: Pain is subjective. The patient's own verbal report is the single
most reliable indicator of pain. While vital signs and behavior can provide
clues, they are not always accurate.
7. The nurse is providing oral care to an unconscious patient. Which position
is safest for this procedure?
A. Supine with a small pillow under the head.
B. Fowler's position.
C. Side-lying position.
D. Trendelenburg position.
Correct Answer: C
Rationale: The side-lying position allows drainage of fluids and secretions
from the mouth, preventing aspiration.
8. A patient is prescribed a liquid medication. What is the most accurate way
to measure the dose?
A. Use a standard household teaspoon.
B. Use a calibrated medicine cup.
C. Pour the liquid directly into the patient's mouth from the bottle.
D. Use a disposable plastic cup.
Correct Answer: B
Rationale: A calibrated medicine cup or an oral syringe is the most accurate
way to measure liquid medications. Household utensils vary significantly in
size. The dose should not be "eyeballed."
9. The nurse is preparing to apply a warm compress to a patient's inflamed
joint. Which of the following is the most appropriate action?
A. Apply the compress for 45 minutes to ensure therapeutic effect.
